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t : Waste Tire 01j � 1 y & Inspection Repel"Inspection Report Number <br /> ■ Ilt State of California <br /> CIWMB 181(New04/04) Survey Form - Page 1 I 1 - 1127693 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> _ <br /> Business Profile Inspection Details <br /> TPIDSite - 4 Inspection Type (Fill-insp O O <br /> Site Suffix: Routine Re-inspection Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Soul 1 n �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Llr Inspected By Inspector <br /> �� AJ() N Smank <br /> Physical Address 3 O f 1JPin �(� <br /> V1 �iw Ave , v7� <br /> 5 <br /> CA 9S�r Inspection Date j o U <br /> Time In Time Out <br /> Business Rep Title �: � O O AM � I S 0 AM <br /> PM <br /> ® PM <br /> v` q� Ahui SaICsm _ Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a Active ® Passenger ® Generator I® Outdoor <br /> 0 0 Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O Q Inactive O Truck <br /> Longitude – 0 Planned Q OTR O 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 0 Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler- O Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS l <br /> O O Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> O O 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 /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred I CIWMB Enforcement <br /> O 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 ® In Compliance - No Violations <br /> ,0 , 0 Other: § <br /> Comments <br /> 1)0 V�0`0.��o�S ( ut_feu fig_ Coq <br /> i t c e c i et� . <br /> o���. 1 s <br /> Inspection Form Included: a ^ <br /> Comments included: 0 — — ��� - a���� I / <br /> usiness_ep's Signa ure Phone Number Insp or's Signatur Phone Number <br /> INSTRUCTIONS ON BACK f Correct:* Incorrect: (I }� �y 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop :LE ® 0 <br />