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Waste Tire Su0&y & Inspection Reportanspection Report Number <br /> State of California <br /> CIWMB181(New 04104) Survey Form - Page 1 i - 1 0 10 7 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> I <br /> TPID- Inspection Type (Fill one) <br /> �, T t, 5 _1 Site Suffix: r� Q Routine Q Re-inspection 0 Referral Q Observation <br /> Local `` �"� If Referral,choose referral type(Fill one) <br /> Identifier: ` f�((' .'%A j rk ( O CHP O CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name <br /> � Inspected By Inspector <br /> 2 P 1 --d <br /> - _ <br /> Physical Address > I .�(,�✓L,t_ Fr4 £ <br /> VIIJ <br /> Street l m l <br /> Inspection Date <br /> C� CIA <br /> J <br /> City StateZ/P Code Time In Time Out <br /> Business Rep TitleO AM O AM <br /> ° - 0PM � ' 0 P <br /> Operational Status Ire Type Business Role orage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) ill all that apply) <br /> Tire Count (Who11 le/PT !- U mil <br /> Q Active Q Passenger a Generator Outdoor <br /> I <br /> GPS Latitude O Q Closed 0 Altered <br /> � . <br /> O Hauler O Indoor <br /> D Inactive 11 O Truck <br /> Longitude — Q Pla enn d OTR O End-Use O Container <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> -- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / Fp / m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 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 O In Compliance - No Violations <br /> Q O (Other: § - _A IL <br /> Comments <br /> r�( I:'.iC✓�� {' VIS"� (' P i i1.{' i�lCt-�P . 7iv !V v ,�y'. : VJO <br /> tUi' '���t-�'1 `t°� CJr ��(' tir�� � ;.. <br /> GU << `+ ` �. A rb+ i.� f `/ t a_.t.(+C. I G o 't I J 4, I i•'1;'k dc c i, =�.. <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X „E xTA, y.jP � E Z ' 2 3 62031 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />