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„ Waste Tire Survey & Inspection Report inspection RD�iAi�VW <br /> CIWItW <br /> ,r Survey Form - Page 1 1 4 . 1 0 1 0 7 6 0 <br /> 1(� oMB 181(New 04!04) <br /> State f CalilornW Y <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN_ <br /> Business Profile I Inspection Details <br /> TPID- u Q Inspection Type (Fill one) <br /> Site Suffix: I I a O O I ®Routine Q Re-inspection p Referral Q Observation <br /> Loral r�� If Referral,choose refenal type(Fill one) <br /> Identifier. ! BGt Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> i 5777 L� &.� i <br /> hysical Address <br /> �XPreSs <br /> I Street <br /> an, Inspection Date <br /> I <br /> UI Time In Time Out <br /> City -State ZIP Code <br /> Business Rep Title OAM O AM <br /> w m �OPM ELI 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> ( (Fill one only) (Fill all that apply)', (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) I <br /> ' 1 ®Active I Q Passenger ®Generator 0 Outdoor <br /> r O <br /> GPS Latitude Q Closed Q Altered W, 1 Q Hauler Q Indoor <br /> L __T_-1 ]-- <br /> Q Inactive ®Truck <br /> Longitude _ �I ,F7 I I I I Q Planned Q OTR Q End-Use Q Container <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 /> ®service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A i HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> IQ Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m /m / m <br /> Q O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Manifest Farms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§119461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O ! 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q Q Other: § �n- <br /> Comments i"vatf&lXktWC}�Ar•`- <br /> S <br /> C/GLS r` i�t. j <br /> Z �fv�,r�wtin +I! �e rl <br /> ►Nts� do rzof jcritbt <br /> I.hc,F ayaa,eIle 1_h -— r.40 <br /> i�o�n1� 1ucrits. <br /> Inspection Form Included.Q r - q <br /> Comments Included:® <br /> Buslness Rep's Sit ature Phone Number sp tor's g ture Phone Number <br /> - � 62081 <br /> ■ INSTRUCTIONS ON BACK Correct:• Incorrect: �/ EXAMPLE 12 3 <br /> Whae Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ■ <br />