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C r _ ■ 1 <br /> c <br /> FORM NO.M-105547-CIWMB M12 1�. .9 967654321 <br /> ■ "1a Waste Tire Survey & Inspection Report Inspection Report Number <br /> I■i7 State of California <br /> i�T$ CIWMB 181(New 04104) Survey Form - Page 1 - 10 7 3 1 <br /> California Integrated Waste Management Board <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 9 Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Re-inspection 0 Referral 0 Observation <br /> Local ' If Referral,choose referral type(Fill one) <br /> Identifier: S�t �O` /7 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> ��j��<� <br /> _87 cz..-��!�� �•-•t^ �/Y�-°may) `v — v� /L���L.�%S2 <br /> Physical AddressZ/3A0 JYj �`1"14 <br /> zj`/ 7/ <br /> Inspection Date f / �� / } <br /> Time In Time Out <br /> Business Rep Title ) / <br /> / 0 PM l i� �r 0 PM <br /> - --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> # Active * Passenger 0 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer ®Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 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 FTI / M / El <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 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 (� In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> - tv `z�,'T�'>.��5' �" �� 7�-v'� ate. e�,`t►'e a.� ?� %�-.-t �,.� <br /> Inspection Form Included: 0 <br /> �Comments Included: <br /> _ 0 Bus es p's 1 nature Phone Number Inspector's Signature Phone Number <br /> 69081 <br />