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Waste Tire S6@.&y & Inspection Repo1Q Inspection Report Number <br /> .Si State of California <br /> - CIWMB181(New 04104) Survey Form - Page 1 I 4 - _i 0i 7 9 2 5 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> i <br /> Business Profile, <br /> t' "` Inspection Details� o �- <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' ® Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: Snr1 ToQq wr' Coun cJ- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> St e CAen z g. . I <br /> � 31 <br /> _Physical Address __ - q I O I V <br /> I Y i 5t�an L..ld c cis <br /> 619 -Z.eah q c CGS. <br /> Street I 1j <br /> Inspection Date � 1 � / [�/E,5 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> � • [ 0PMi 0 <br /> 10 Bbu dzrs „ Admin . -- - -- <br /> 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 /> 0Active 0 Passenger Q Generator Q Outdoor <br /> L1 ' D Q Closed Q Altered <br /> GPS LatitudeF T_ Q Hauler Q Indoor <br /> _ 0 Q Inactive Q Truck i <br /> Longitude — l Q Planned Q OTR Q End Use Q Container <br /> I <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 Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other C0I)Sir(AGA 4o f) CornlyA�} <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS -- � <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 m 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> -d�N,_ri2r-�i �N�a --a�aS �.� o n—moo c ou.�1 -tin is _ cry - — <br /> �'�. f <br /> 1 as 1cl�qq <br /> 17 I o knave ---tav q <br /> or <br /> Inspection Form Included: Q ' , <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Inspebv s Signature/'. V-� Phone Number <br /> 213-1 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �. \/ E A nth F L I 1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />