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Waste TirEl, 10vey & Inspection Re0o Inspection Report Number <br /> ■ ii State of CaliforniaC1WMB 181 04/04) <br /> ■ <br /> california Integrated Was eeManagement Board survey Form - Page 1 Il - 1127666 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 6 � - � � Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L4�-�Cx;�C6��1y1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name :- Inspected By Inspector <br /> Physical Address <br /> q C&i LSA 61-o-f ---- <br /> L� Inspection Date <br /> Time In Time Out <br /> Business Rep <br /> M�.'^,y� ( Ti(tle�, O AM �� ®pM <br /> AXV, `lJl� l t/1�A(f PM p[ <br /> -- - - --- — - --- - — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' 100 <br /> 0Q '(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ® Passenger Generator ® Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS ® Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - <br /> 9 Q Planned Q OTR Q End-Use i Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 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 /> V A HAULING AND MANIFEST REQUIREMENTS 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 <br /> m / m <br /> Q Q 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 (Required for NOV or EXT) <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 1 10 In Compliance - No Violations <br /> Q Q Other: § <br /> Commentsj� - <br /> Z�Yz � f ccc c 1. ` i K <br /> Inspection Form Included: Q <br /> Comments Included, = ! �� <br /> Business Rep-s Sign re Phone Number I p ct - ignature Phone Number <br /> -- - - - <br /> INSTRUCTIONS ON BACK ' Correct: _Incorrect I � E 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py: <br />