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Waste Tire SL y & Inspection Repor Inspection Report Number <br /> State"i11i1 <br /> CIWM f 81(Nrnia Survey Form - Page 1 1 7 - 1 Q 7 $ 0 4 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey __ BLUE OR BLACK_ INK PEN <br /> Business Profile Inspection Details <br /> TPID- I O 6 O q Q - l Inspection Type (Fill one) <br /> Site Suffix: V 0 Routine 0 Re-inspection 0 Referral Q Observation <br /> LocalT l If Referral,choose referral type(Fill one) <br /> Identifier: Sart .lbaguln Couh` y 0 CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> C' P Y Inspector <br /> L 11-t -Tr u ck 5 e.�v l ces I, stn c„ <br /> Physical Address 3 _C( U Klls+lm LL-ecctS <br /> _L5385 5• 5C,A VIM <br /> GA g5317 Inspection Date d 3 2 U 8 <br /> .TrQc� <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM Q PM <br /> Gre QCcAn oi6n Ptes►C6_(nt - -- <br /> --_ -- — — - --- Operational Status Tire Type ype Business Role Storage Type <br /> Tire Count(Whole/PTE) ;/ O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f Z 'T 0 Active • Passenger ® Generator *Outdoor <br /> O 0Closed 0 Altered <br /> GPS Latitude O Hauler O Indoor <br /> O O Inactive Q Truck <br /> Longitude - Q Planned 0 OTR O End-Use Q Container <br /> Business Type (Fill all that apply) 100 mii <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government O Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> O Service Station Q Hauler Q Agriculture Q Shredder Other For'A4+ S.eYvIce/ze)f!NY4sol <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS` <br /> i HAULING AND MANIFEST REQUIREMENTS . i. <br /> — - O Notice Of Violation O E efisi <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O 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 / <br /> O O 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 /> 0 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 • In Compliance - No Violations <br /> 0 Other: § - <br /> Comments <br /> Routt rtie. �ns�-�,o ��:�9�t�s�-th6 c�cti-e � -tom. -�ollot�►n� � ncs�ec�� <br /> �o( w a5+e -���e o u,t_r� • ��lnc�s_ � Ct�1 c �T t gyres <br /> Arra__ sc � s►r�ce Lo�_. ,�pT oM_ 4 �er --�C s <br /> Inspection Form Included: Q _ (ZOO <br /> Comments Included: ® /aire <br /> me s SI Phone Number Ins is Signatur Phone Number <br /> 62081 <br /> INSTRUCTIONS BACK Correct 9 Incorrect i E� �� F 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />