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® W; Y!�ste Tire urvey & Inspection Report Inspection.Report.Number ■ <br /> California _ <br /> 9,c4ia� CIWMB1 <br /> 181(New04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Bo d <br /> Part A- Survey, _ BLUE OR BLACK INK PEN <br /> Business Profile A, j Inspection Details _ <br /> TPID- �� Inspection Type (Fill one) D <br /> Site-Suffix - s RE - [El— ® Routine Q Re-inspection Q'ReferralURs <br /> Local C� C i If Referral,choose referral type(Fill one) JUL 2 0. 2010 <br /> Identifier: t F'�. f C LC Ytf..�, Q CHP Q CIWMB Q Complaint i Ot ur <br /> EPJ(i�'�91 MAI T <br /> Business or Facility Name / bU}1^ 0f (�c��J _I{;-f/� Inspected By Inspe RM1T/ERV10ES <br /> i <br /> Physical Address �f �1.�. � <br /> 1 Jb vr ! [J.D1 10W. <br /> Street .t t�-. Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep TitleEJOAm O AM <br /> 4-1 yt, } L= : PM m —_ O PM <br /> Operational Status Tire Typ>— Business Role Storage Type <br /> TireWFOle/PTE+ ; I i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> o <br /> Active Q Passenger Q Generator Q Outdoor <br /> �O Q Closed Q Altered <br /> GPS,- Q Hauler OIndoorLatitude <br /> Long itude �- , . � O <br /> Q Inactive Q Truck <br /> Q End-Use ; Container <br /> Q Planned QOTR <br /> I <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body 0 Car Dealer . Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Agriculture Q Shredder @Other ^Cc�Q• 1 11�/t T P _ <br /> - <br /> - <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT_ STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation Q Extension <br /> O Q <br /> PRC,§42951 -Waste Tire Hau er Registration and Transport of Tires <br /> O O P-RC§42953-Contracts with F Itegistered Waste Tire Haulers. Compliance Deadline <br /> O O PRC•§42956-Registration/De al in Vehicle <br /> �I4.CCR§-18459 -Responsible Entities Complying with Manifesting Requirements Date m m m <br /> O O 14 CCR§18459.1 (a)(b)(c) ire Program ID Number from CIWMB <br /> r 14 CCR§184592.1 SubmittE I of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O .O. 14 CCR§18459.3-Retention f Manifest.Forms and Tire Trip Logs for 3 years <br /> O O 14 PCR§18460.2-Manifest ystem'Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> O .O 14 CCR§18461 -'Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§:18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators' <br /> O O 0 In Compliance - No Violations <br /> O O Other: § <br /> Comments �!�Il�.. <br /> Ct(,4I.t� tI f a .A V1 Ut (cXtC'd ce_Of6 (loo 0..✓ C_L� <br /> a ,��-� VI/4 iCf ,, Uf�'l�� YP f i�.rn tA��!!� -hire �} �oU J,_.�:_'} ;?��- o - � �er ti.(�•: <br /> y{,t , f '2 ' G r t ,� s t� �rt� Ct hCl. r C)?,f( � i l - <br /> r V <br /> Inspection Form Included - K <br /> J t1 I 11 ! t. i I ,. <br /> Comments Included: , t Z.lt' '� .. t.. _..±_L . <br /> _ , ._ t _ <br /> Busines Rep's Signature Phone Number InsjSt Ftor's ignature / Phone Number <br /> — – =--- --- — --- _ -- —�— -- -- 62081-- <br /> , <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: IA C==-?� A �.F,I P L �� 113 <br /> T 1 2 <br /> - -------------- ----------------- ---- <br /> W ite Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ' M <br />