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`r =� <br /> LEPE'P- <br /> - CJWS y & nspectionRepo TInspection <br /> Report NumberWastire <br /> State of California <br /> MB 181(Ne�v 04104) <br /> California Integrated Waste Management Board 1O R vTSurvey Form - Page 1 s <br /> ■' <br /> Part A, Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j-. Inspection Type (Fill one) <br /> Site Suffix: 10) Routine Q Re-inspection Q Referral 0 Observation <br /> Local - f If Referral,choose referral type(Fill one) <br /> Identifier: L6LLAO CHP O CIWMB O Complaint Q Educational Visit Q Other <br /> Busi:;psor Facility NameQ t� t� Inspected By Inspectort� 1Lj <br /> +,, <br /> Physical Address ! �V`,Y 1 y <br /> I 1 7 gn r <br /> Street I I <br /> �j Inspection Date <br /> I <br /> City State ZIP Code' Time In Time Out <br /> Business Rep Title QAM Q AM <br /> L L3S �/' IE : <br /> 0 PM ELI • m 0 PM <br /> Y r Operational Status Tire Type Business Role Storage Type <br /> (� r (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Active Q Passenger 0 Generator ® Outdoor <br /> Latitude 0 Q Closed O Altered <br /> GPS � • Q Hauler 0 Indoor <br /> O O Inactive Q Truck <br /> Longitude — ! O Planned ® OTR O-End-Use O Container <br /> Business Type (Fill all that apply) <br /> Q New°Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer O Collection O Crumb Rubber . <br /> Q Service Station Q Hauler- Q Agriculture Q Shredder Other / 6 - <br /> - r OA <br /> - <br /> Part B' Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A i HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q. 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 /> .0 .0 14 CCR§18459 'Responsible Entities Complying with Manifesting Requirements Date IE / m / 1:11 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 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 /> 0 O. 114 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 '14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q In Compliance - No Violations <br /> _ 0 0 'Other: § <br /> Commentsho� r r i o <br /> � kb. <br /> Vt.SP aJ. rcf5 ��Gt�ae f if <br /> J7 <br /> �a!�. ` 11 rC.•4' <br /> 1 <br /> .. - w <br /> ZN <br /> Inspection Form Included <br /> Comments Included � )cr's <br /> -us ss Rep'sS-lgnatur Phone Number InspeSignature Phone Number <br /> ------ --- ----_ _ - 62081 <br /> INSTRUCTIONS:ON BACK Correct: incorrect:X r, E,X J.A Ifflil F I L' .2 � <br /> ■ White -_: -- ■ <br /> Copy.CIWMB Yellow Copy:Operator Pinl�Copy:LEA . <br /> - <br />