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AWaste Tire S' y & Inspection Repo IFT <br />ctionReport Number ■, <br />HSHH.c State of California - <br />CIWMB 181 (New 04/04) Survey Form - Page 1- - 10 7.9 2 6 Q - <br />California Integrated Waste Management Board <br />Sart A - SurvPv BLUE OR BLACK INK PEN <br />[Business Profile I Inspection Details <br />TPID - . <br />Site Suffix: <br />Local <br />Identifier: S Ctrl. o ct(lU1 <br />Inspection Type (Fill one) <br />QLd <br />J& Routine Q.Re=inspection Q RefeniaI Q Observation <br />If Referral choose referral typer(,PiH on¢)r, <br />Q CHP Q CIWMB Q Comoamf Q Educational Visit Q Other <br />Business'or Facility Name <br />Inspected By ' Inspector <br />Physical Address , il--�r J:Eft k an Lcw5 # <br />C <br />L4 I F C__hay-�-er Wk a14 t <br />Stree <br />Inspection Date O 8 <br />I -�E)n C'k-ion, C, A, grszo� <br />City State ZIP Code Time In Time Out <br />Business Rep Title OAM O AM <br />_ m'm0PM �'m 0PM <br />Operational Status Tire Type Business Role <br />(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) <br />The Count <br />( ) 7 Active # Passenger Generator <br />O Q Closed Q Altered <br />Storage Type <br />(Fill all that apply) <br />® Outdoor <br />GPS Latitudem , { �,� Q Hauler Q Indoor <br />I ! JJI Q Inactive Q Truck <br />Longitude - <br />Business Type (Fill all that apply) <br />New Tire Dealer Q Auto Repair <br />® Used Tire Dealer Q Auto Body <br />Trucking .Fleet <br />Q Car Dealer <br />O <br />Q End -Use Q Container <br />Q Planned Q OTR <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q. Collection Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture. Q. Shredder Q Other I <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V i <br />A HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 -Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />6 <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />.Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />.ID <br />�n <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />c) <br />Other: § <br />ENFORCEMENT STATUS <br />® Notice Of Violation Q Extension <br />Compliance Deadline <br />Date MOG j M(36 <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />Q In Compliance - No Violations <br />Comments <br />��►s� s� QY_o� 3?ra ,moo-rn-- <br />�'P� <br />t <br />nspection Form Included: Q. <br />Comments Included. /6 <br />Business Rep's Signature_ Phone Number tor's Signature—74-- <br />Phone Number <br />--- <br />- -_-_ -- „ 62081 <br />INSTRUCTIONS ON BACK Correct: Incorrect: } 'X •'Ji P E T <br />White Copy: CIWMB. Yellow Copy: Operator 'Pink Copy: LEA <br />