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It R°- ��yy e pp q Kq <br /> ,` V�i46�5I 8.. <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> �i State B 181(Now Survey Form - Page 1 I 1 - 110E 4 6 7 <br /> CIWMB 181 stew nage y <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �— I Inspection Type (Fill one) <br /> Site suffix: <br /> L , k © 6 y ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalI If Referral,choose referral type(Fill one) <br /> Identifier: - )OA 1� �Qt,fr�, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> A&-R- I <br /> Physical Address <br /> Street l <br /> 9 Inspection Date I I O <br /> L_A� --— - -- -- ��J Time In Time Out _ l <br /> Ciry Sta!e ZIH Ccde _ <br /> Business Rep Title O AM -� 0 AM <br /> ® PM I ' C? OJ O PM <br /> Operational Status Tire Type 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 0 Passenger ® Generator ® Outdoor <br /> Latitude D 0 Closed 0 Altered <br /> GPS ® Hauler Indoor <br /> 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR ® End-Use All Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station ® Hauler 0 Agriculture 0 Shredder ® Other L�'_'�0�0 _[W►M1IejS./d / <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS �l <br /> _----------- <br /> —--- -- -- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 ----- 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Ffl / M / Ffl <br /> 0 . 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tir13 Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> 0 j-0. I Other: <br /> Comments <br /> CL,- <br /> 4 <br /> Inspection Form Included: O �•� � l �- 4EX <br /> Comments Included: Business Rep's 1 nture Phone NumbS ature Phone Number <br /> INSTRUCTIONS ON BACK C rrect. Incorrect: ( 62081 <br /> PLE 1 :Z3 <br /> White C y:CIW Yellow Copy Operator Pink Copy:LEA <br />