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091 -3305C'I004 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California 13 <br /> ••�� CIWMB 181(New 04104) Survey Form - Page 1 I 1 - 1088440 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ( 6 l 0 ' Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� -0 Q CHP Q CIWMB 0'Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 7--75'0 ((�'� (�,, I^ <br /> Physical Address 3 -1 - b 1 ���+r�� Av amhv"� <br /> 11-1,' C• �ccl�er �c� . �����14 <br /> Inspection Date <) L/ <br /> !` t <br /> Time In Time Out <br /> Business <br /> ReRep <br /> ^ Title m AM J I ®AM <br /> OrrDn a Q O PM / l O O PM <br /> ---- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fil(all that apply) (Fill all that apply) <br /> t f 6 Active Q Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other plpi� M(e TtcL%1_[5 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT,S ATUS ;' <br /> y --A-?/ AND MANIFEST REQUIREMENTS ;,' „ -, F <br /> Notice O1 Iola on Q Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires .' 1 <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance.Meadline a <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements Date; / ;'i m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB � <br /> (Required foc NOV o[ <br /> Q O14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days $` <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire HaulersQ ReferredCIWMB Enforcement <br /> Q Q 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 <br /> ® In Compliance - No Violations <br /> Q IQ Other: § AL <br /> Comments <br /> Inspection Form Included: Q �6 9 <br /> Comments Included: <br /> Busin ss Re 's ure Phone Number Inspe tor's Pi'§Aature Phone Number <br /> - - - 62081 <br /> INSTRUCTIONS ON K Co r I_correct: '� E X A M P I Z 3 <br /> White Cop :CIW Yellow Copy.Operator Pink Copy:LEA <br />