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��ey & Inspection ReporbIns e-ction Report NumberSWaste Tire <br /> —2a. State of California T 1 _ 1108464 1 0 8 ®� 6 4 <br /> • CIWM6181(New 04/04) Survey Form - Page 1 11 11 `°i' <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: <br /> uffixL(� W 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: r ( ,� t�'` �� !.I (: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name _ Inspected By Inspector <br /> Physical Add ss i 1 <br /> L c I <br /> Street Inspection Date <br /> — � Time In Time Out <br /> City State Z!F'Ccde _ �.._ <br /> Business Rep Title ( I ` 1 Q AM n� AM <br /> e <br /> riIC F t j�, '�-�-r�Fr; • � QPM ;(� L.J PM � <br /> I <br /> (Fill one only)lStatus Tire <br /> Ilythpe apply)' (Fill all that apply) Storage <br /> all that T apply) <br /> -s-- _ Business Role Stora e Type � <br /> Tire Count(WholelPTE) �j <br /> Active 0 Passenger Q Generator 0 Outdoor <br /> O I O Closed 0 Altered <br /> GPS Latitude ! � , � � 0 Hauler 0 Indoor <br /> L III _III L _,O 0 Inactive 0 Truck <br /> Longitude — j 0 Planned 0 OTR 0 End-Use 0 Container <br /> �- - - � l .F_F ! -- <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder (V Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS_ - <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> CR 18459.1 -Tire Program ID Number from CIWMB <br /> 00 114 CCR§ 9 <br /> DID 14 CCR§ p p 9 years (Required for NOV or EXT) <br /> � 14 CCR§ 18459.3 1 Retebtilotnaof Comnrehens ve Tri rlpo ogfow3hi0 days --- <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 14 CCR 18461 -Manifest System Requirements for Waste Tire End-Use Facilities I <br /> 0 0 § Y q 0 In Compliance - No Violations <br /> 0 0 1Other: § <br /> Comments l C-:—, 41— f. ! — <br /> r <br /> } <br /> Inspection Form Included: 0', <br /> Comments Included: 0! - xi <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X A MI P L E j 1 -2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA i <br /> L <br />