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Waste■ Tire Survey & Inspection Report Inspection Report Number <br /> State of California Survey Form - Page 1 1143656 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey_ <br /> j <br /> Business Profile Inspection Details <br /> TPID <br /> Inspection Type (Fill one) <br /> - <br /> Site Suffix: l a ' Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name l Inspected By Inspector <br /> L <br /> ;S1 <br /> Physical Address Ct A A1673o <br /> &, Ilbf-cakcr <br /> q5oQ C)6 Inspection Date C) <br /> �:)k 0&�%�Vn Time In Time Out <br /> Business Rep Title <br /> 0 AM 0 AM <br /> 0 PM Ll C) 0 PM <br /> ZeeJ llee�kcw-c- Storage Type <br /> Operational Status Tire Type Business <br /> (Fill one only) (Fill all that apply) (Fill all thatapply) (Fill all that apply) <br /> s R <br /> Tire Count(Whole/PTE) ®Active 0 Passenger Generator Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 inactive (6 Truck 0 Hauler 0 Indoor <br /> 0 End-Use U Container <br /> Longitude 0 OTR <br /> 0 Planned <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Trucking Fleet 0 Government 0 Retr ader 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 Other 10v <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FENFORCEMENT STATUS <br /> V A i HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Compliance Deadline <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB (Required for NOV or E)M <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 <br /> ,L614 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 0 Other: § <br /> Comments <br /> Inspection Form Included: 0 -7 <br /> AVI� umber <br /> Comments Included: *�Business Rep's Signature Phone Number e or's -'-nature - Phone - <br /> INSTRUCTIONS ON BACK Correct <br /> 62081 <br /> A M 'I L 1112 <br /> A , <br /> :0 incorrect: X <br /> ■ White Copy:CIWMB Yellow Copy:operator Pink Cop <br />