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Waste Tire Su <br /> & Inspection Report nspection Report Number <br /> C'Rd Stateof BCalifornia Survey Form - Page 1 I1 - 1140613 <br /> CIWMB 181(New 04/04) Y ry <br /> California Integrated Waste Management Board y <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �i Inspection Type (Fill one) <br /> Site Suffix: V C) d ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: „ t w Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Lc�4 's LLC q <br /> Physical Address .3S0004 C4,1— <br /> C)Ram - <br /> Inspection Date � O � � � � / U <br /> kc =� C �JS33G <br /> Time In Time Out <br /> Business Rep TitleO AM / Q AM <br /> f� (�� t d C) ® PM ` Z 2 O ® PM <br /> -- k.f'C-u �o�s "�W1'�G�P� <br /> -- �_Op_erational Status Tire Type Business Role i Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> p Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q 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 /> 10 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber f� _ <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other G VCr`, ,Cie,S S/l�.t{/ 't r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS i <br /> p y f <br /> V A 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 /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> ! <br /> Q 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 i CIWMB Enforcement <br /> Q O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> I <br /> Q O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> i In Compliance - No Violations <br /> Q O Other: § - <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included:�. - Whatu <br /> - l -/ Gr/ 6r 0E' 3 <br /> Business RPhone Number I ector's Si nat a Phone Nur►tb®r <br /> - --__ . 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ! Xi R M 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy: E <br />