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0812904111 <br /> Waste Tire Survey:& Inspection Report . Inspection Report Number <br /> State of Callfomia <br /> CIWMB 181(N..OW04) Survey Form - Page 1 ..I. 2 . 10 10 8 5 -8 <br /> California Integrated Waste Management Board <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business'Profile Inspection Details <br /> Site - / / 3 C2 _ O / Inspection Type (Fill one) <br /> Site Suffix: — -- Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local (� If Referral,choose referral type(Fill one) <br /> Identifier:. GI/L /0'2 a0 CHP 0 CIWMB 0 Complaint 0 Educational-Visit 0 Other <br /> Business or Facility Name Inspected By :nspector <br /> Physical Address <br /> Street /- Inspection Date ( p <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> �a/��� G"rllGG m m0PM m 'm OPM <br /> L" - — I__ _ I Operational Status Tire Type Business Role Storage Type <br /> l I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) t I� -It <br /> ®Active ®Passenger 49 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> m. <br /> GP$ Latitude 71 T1 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - FFFI-I I I I <br /> 0 Planned 0 OTR 0 End-Use 0 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 0 Hauler 0 Agriculture 0 Shredder 0 Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMEN.17 STA1TLUS_ <br /> — -- <br /> rVj LING ffND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation !�F_xtension <br /> 0 0 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 <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXTJ <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred 1 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 Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 1 0 Other: § <br /> Comments <br /> Inspection Form Included: CC`` �j aim/ ! //o L Z4�r <br /> Comments Included:0 —=y oli l - ���� " -' y68-a <br /> Business Rep s Signature Phone Number. Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Corrteci: 62081 <br /> �_ Incorrect: E X A M P L E 1 '2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® S <br />