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0921004GS16 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> • °° <br /> State of 181CaliforniaowI 1 10 8 6 9 01 <br /> Survey Form - Page 1 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> _j <br /> Part A-Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- In <br /> spection Type (Fill one) <br /> Site Suffix: I 5 I-7 g - b I0 RoutineQ Reins ection <br /> p Q Referral Q Observation <br /> Local y, 1 If Referral,choose referral type(Fill one) <br /> Identifier: Sane 1! •`� , iO CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility <br /> \Name Inspected By Inspector <br /> Physiiccal Addrel1�-11'1 <br /> L-9 0o /NI G,c�-og� - <br /> Street <br /> K-�j / QC�1 Inspection Date <br /> �- <br /> �N19C '""_ `� + `` "t �� Time In Time Out <br /> City Sta.e ZIP Code <br /> Business Re Title —, 1®AM —� Q AM <br /> P I ` I5 �0PM `—� I . � QI �J0PM <br /> _ower- - ----- �--1 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 �1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r r l l ®Active Q Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> -- — - -- - - - - Q Inactive ®Truck <br /> - -- --- - - --. - - _ 0 <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other l I <br /> Part B- Inspection of Waste Tire Dealer, Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 01 A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Bompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m <br /> Q Q 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 /> Q 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 /> Q 1 Q 1 Other: § <br /> Comments -/ '�c cbn <br /> A tel,i, a�G f'1�1Y! l c3Y /QYf°![ S r1I OYI L��rj <br /> Inspection Form Included: Q _ <br /> Comments Included: Q <br /> ' -Y 7 <br /> Business ep s t atu Phone Number In or gnature Phone Number <br /> INSTRUCTIONS ON BACK Correc I IEIXIAIMIPILIEI 111213 <br /> 62081 <br /> ■ White Cop .CIW Yellow Copy.Operator Pink Copy:LEA <br />