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l Waste Tlre' y & Inspection Reports Inspection Reprt Number <br /> AM <br /> State of California <br /> CIWMB 181(New 04104) Survey Form = Page 12 - 13,7 .0 <br /> California Integrated Waste Management Board F71 <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> f TPID - Inspection Type (Fill one) <br /> Site Suffix: ! ( < U 1 @,Routine 0 Re-inspection Q Referral Q Observation <br /> Local (� If Referral,choose referral type(Fill one) <br /> Identifier: 41 OG t� �� (. CHP CIWMB Complaint Educational Visit Other <br /> 0- 0 � P � 0 <br /> Business or Facility Name Nap- <br /> l - <br /> --j I Inspected By Inspector <br /> Physical Address �) EE ( Il/ ,J e, �Pg. L Z <br /> I } o j j cl J I ,v�` AA/(j Ll <br /> I --- <br /> Street `( t`j <br /> tIns C� <br /> /� t�- � S <br /> I 'A o /4C r'l '. Cl � .�y oJ I <br /> City State ZlP Code Time In Time Out <br /> Business Rep Title f f� AM / 0 AM <br /> l/ J V D PM V V ®'PM <br /> ►�•l �� �C t`, �t Sty{ (�,,. ( (of<I t, ---— <br /> (Whole/PTE) <br /> /y Operational Status Tire Type Business Role Storage Type <br /> Tire Count ❑ / V (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> } � �. <br /> Active C)Passenger (5 Generator 0 Outdoor <br /> O O Closed Q'Altered <br /> GPS .Latitude m . Q Hauler 0 Indoor <br /> O <br /> Inactive b Truck <br /> Longitude - O Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader O Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler O Agriculture Q Shredder O Other I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Vi q HAULING AND MANIFEST REQUIREMENTS <br /> - - -Hauler PRC§42951 -Waste Tire auler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 1:11 / 1:11 / E[1 <br /> O O 14 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 <br /> (Required for NOV or EXT) <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -,Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q O Other: §{ jj t J ( ` ] <br /> Comments '(. {tft, /1/ 1 Cf f+ \ti foil tl i ti1(` (I t` t C{ t �.t j ]n L' r f 4-1 <br /> I t t vFi u t i y 7 iL I I ►_ <br /> '; � y fr <br /> et(if rr�r" ,- �,+tc- r Cl1 t �:` ' d^.�. rCA_`( 5 l?v�C� �,'J;G� GCCttr�? tZt <br /> ti <br /> bi a7f wAon WC� 'CL a f f 1S f j6G4,L( . Bpt ow- Tire t' o)twc 50-)(V <br /> 1c� s abot.1 - '� /IPwe <br /> Inspection Form Included: 0! <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number/ Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:0 Incorrect: X t� `/jI I X J.A IM I p-I L I E 1 111213162081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA S <br /> 14 <br />