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0.9161,04:004.6 <br /> Waste Tire Survey & Inspection Report Inspection Report Number. <br /> State of 181(Now <br /> Survey Form - Page 1 1 6 - 1 0 1 9 3 2 8 i <br /> CIWMB 181(Naw 04/04) <br /> California Integrated Waste Management Board <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l 6 17 I 9 I ,��� - I 0 I ( I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ( If Referral,choose referral type(Fill one) <br /> Identifier: I ��n �Q n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> l <br /> Physical Address <br /> /790o <br /> Street <br /> Inspection Date •s- / -z I 19 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title /� *AM <br /> DIvJ*AM <br /> 0PM I � I ' I Q / 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) <br /> ®Active Passenger I& Generator Q Outdoor <br /> ` i I O Q Closed Q Altered <br /> GPS Latitude I • I I Q Hauler Q Indoor <br /> L-L �- - L- ----'—= Q Inactive 0 Truck <br /> ---- -i- - - --— <br /> Longitude - fjo <br /> 7j0 <br /> Planned Q OTR Q End-Use 0 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility . ENF"ORGEMENT STATUS <br /> V AHAULING AND MANIFEST REgUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> QQ 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Re wired for NOV or FXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In C-ompliance - No Violations <br /> Q Q Other: §, <br /> Comments <br /> ��ze,•ei" ccl� ��� — �►-� (face-i'y -r�u /c��o✓� �/ i./ k r� <br /> r ur �?� ��/ r I//..r/�� Ctp p n /� �•� 1 Gt c�Ors-4"i s� <br /> 7 <br /> ,04 au, <br /> Inspection Form Included: Q <br /> Comments Included: Q �� 5873868 �/ d4�� � k-� �6�033A <br /> bulkiness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK . Corre In •rrect: I��xI.A�AhI P f I I I'2I 3 I 62081 <br /> White Copy.C M Yellow Copy.Operator Pink Copy LEA �� <br />