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osisioGo��s <br /> Waste Tire-Survey & Inspection Report Inspection Report Number <br /> �r State of California <br /> CIWMB 181(New Management <br /> Survey Form - Page 1 1 8 - 1 0 7 9 2 2 2 <br /> CaII/omla Integrated Wasta Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection.Details <br /> TPID- I � _ m Inspection Type (Fill one) <br /> Site Suffix: 4D Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: JO_ O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business orFacilityNamely Ins ectad B <br /> hP ysical lAddlesss��`Y �P�bfN� P Y- Inspector <br /> 39 id l �� a I <br /> Street <br /> !�'� A ^��! i Inspection Date <br /> City [�/+ State ZIP Code Time In Time Out <br /> Business Rep Title O AM m <br /> L-1�J O AM <br /> Jr C/f �/_ (4 /A_A J O PM O PM <br /> -JQ -- — -T-�- - - 'J-I ----M-N-�K- <br /> --- Operational Status Tire.Type Business Role Storage Type: <br /> Tire Count(Whole/PTE). / t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> .01 <br /> 0 Active O Passenger 41 Generator 0 Outdoor <br /> I 0 O Closed O Altered <br /> GPS Latitude —�,, . I— — I I O Hauler O Indoor <br /> 1 J—JO O Inactive 0 Truck <br /> I <br /> Longitude - I I I I O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) 1 <br /> 0 New Tire Dealer O Auto Repair 0 Trucking Fleet O Government. O Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer 0 Collection O Crumb Rubber <br /> i <br /> O Service Station O Hauler O Agriculture O Shredder O Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A f HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation O Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O ; O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 71 / [:E] / [:[] <br /> O 1 O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O. 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or DCT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> O O Other: §, <br /> CommentsI_ <br /> ot,-Ainl <br /> --w�o+r�� 2�.�s—��'l_��_tJ_�.u_�i_J,'!s�—�_c��.c��r_'re��s �11if✓� r�-�s- - <br /> Inspection Form Included:O?Bun <br /> Comments Included:O <br /> ss Rep's ignaturePhone Number Inspector s Signature, 62081 <br /> INSTRUCTIONS OK C rect 40 Incorrect:�(� l�J t X A M P L E l 2 3 <br /> ■ White Cop CIWM Yellow Copy.Operator Pink Copy LEA ® ■ <br />