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Inspection Report Number <br /> Waste Tire Su. ,iey & Inspection Repo► . <br /> • ;II3� lif <br /> State of Caornia - <br /> CIWMB181(New 04/04) Survey Form - Page 1 t u u o G $ <br /> • California integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey_-_ <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspe-'3r Q Relerral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Ccmpla rt Q E�.:cational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date J S <br /> Time In Time Out <br /> Business Rep Title AM <br /> 1 l Q PM <br /> L) -11­ lJ <br /> Operational Status Tire Type Business Role Storage Type <br /> _ (Fill one only) (Fill all tra'app'!y) FJI ail:-a:acply) (Fill all that apply) <br /> Tire Count (Whole/PTE) , c9 C7 <br /> ® Active Passenger G­--'a'ir ® Outdoor <br /> 0 Q Closed Q <br /> GPS Latitude Ha__' ® Indoor <br /> Q Inactive Q T <br /> Q <br /> Longitude - Q Planned Q 0-1 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 D smantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q 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 /> ---------- <br /> ®Notice Of Violation <br /> 0 ®• 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 m <br /> 0 14 CCR§ 18459 -Responsible Entities Complying with Mani s�lgg Requirements Date <br /> 0 Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from ClB I I I <br /> Q 0 14 CCR§ 18459.2rip L (Required for NOV or EXT) <br /> .1 -Submittal of Manifest Forms and Tire Ts within 90 days <br /> Q 0 14 CCR§18459.3-Retention of Manifest Forms and Tirerip Logs r 3 Years r"4 <br /> 14 CCR§18460.2-Manifest System Requirements for Registered VNaa e Tire Haulers �ATM1EMg <br /> 0 'v <br /> 00 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 <br /> 0 0 Other: § <br /> Comment 'L IN "`' t n. y0c, <br /> �I.S iT��y 1rJ mak- T�� 1�1 V�aw�.�G �'b� D�.C.t �.oLa.�C•y`�S CS�.'. �t.�w,, <br /> - <br /> 5 <br /> Inspection Form Included: <br /> Goo <br /> Comments Included- Q Insctor's Si nature Phone Number <br /> B si s s l a - Phone Number P 9 - <br /> — -- - 62081 <br /> INSTRUCTIONS CK Corre Incorrect: X E ?�; P !� = L 1 <br /> White Copy CI'N,%16 Yellow Cocj Ciper3t�: <br />