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_ C C, C CC 0 C, C. C C) C' <br /> FORM NO.M-105547-CIWMB M12 1607 519 987654321 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of Survey Form - Page 1 - 0 l 4 3 0 <br /> CIWMBB181(New 04/04) Y <br /> California Integrated Waste Management Board <br /> Part A- Survey - -_ BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> TPID- ��yy tt Inspection Type (Fill one) <br /> Site Suffix: 3 -I 3 I IS Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1 n <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -- — <br /> Inspected By Inspector <br /> �in�-tx 5}-cam_ c-&'i C-r>r-f-t <br /> Physical Address <br /> �NtiGt-t�IC.�A-� OG'Y•'I'1 CNS. <br /> C.}. <br /> Inspection Date C) I I <br /> C-A q S2_3 1 <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> ® PM A PM <br /> Operational Status Tire Type y Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> -- ---- _ <br /> fO ' A �'�,HAULING AND MANIFEST REQUIREMENTS <br /> - 1- -------- - — - -- - ---- -- - O Notice Of Violation Q Extension <br /> Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> ® Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> ��, -t•w L,��cr�t�u,-, a-,n �_i- cica: 1 �y:o rnn /} S q. A - - <br /> l_��t:� k�us-_nv�el <br /> �F� / c r,>✓,r.Grr�r,_N E-tc�h It 1�o f�w� _rcc - o1- 's- <br /> - r-}o bac S"c*xc c,7-L S te'k rn,6fcc/ A0 ,g�4 f�tt f"n S - <br /> Inspection Form Included: Q <br /> Cay.) <br /> Comments Included: Q � -ate` y6��pbz3 <br />