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IE <br /> inspection Report aste .Tire SuA_ y & Inspection Report . <br /> -• State of California <br /> L ' CIWMB 181(New 04/04) Survey Form - Page 1 1 2 - 10 0 :6 l 8 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j (� Inspection Type (Fill one) <br /> Site Suffix: t 1 J (.;:=�Rutine Q Re-inspection (Referral Q;Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: 00 � pU.�� O CHP Q CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> I <br /> N Auto �9pa.�' - <br /> Physical Address — �'Yll VL �w(_2 <br /> rt 01 , <br /> L 3y 0 3 IE, Mcg, - <br /> Street <br /> Inspection Date - <br /> I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 'r) Q AM / 0 AM <br /> V 0 P � ' � 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I I I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t ' 0Active (D Passenger (a Generator (5 Outdoor <br /> 770 <br /> o Closed 0Altered <br /> GPS Latitude m , O Hauler C-) Indoor <br /> O O Inactive 0 Truck <br /> Longitude — O Planned 0 OTR End Use Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer )Auto Repair 0 Trucking Fleet Q Government 0 Retreader Q Dismantler Q Tire Derived.Fuel <br /> (a Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station Q Hauler Q Agriculture 0 Shredder 0 Other I <br /> Part B- Inspection of Waste Tire Dealer, Generator,.Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A .HAULING AND MANIFEST REQUIREMENTS i <br /> ' 0 Notice Of Violation 0 Extension <br /> o O <br /> II 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 /> 0 Q i 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> l0 0 114 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q. Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§18459:3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 00 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0- .0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities, <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: <br /> Comments <br /> 1,1 Gf(*AI jrfl ndGiro( ! tl a >? 0+ -t c� i7olv 11 �rtp'r <br /> �0`�� "+ ir S C t�C �w: �. <br /> lhi t'Q c't ai 1 I t <br /> 12 �!C,` ,!t t,-f L) Y t—�Gf — 't F iq I7 s�i f T�,i �c��l <br /> Inspection Form Included: 0 <br /> Comments Included: d. '__ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �te E ' "A� ,�P I I Z 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />