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03214040246 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> I 1 <br /> 01k, <br /> California State of <br /> CIWMB.181(New 04/04) <br /> California Integrated Waste Management Board Survey Form - Page 1 1088364 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Ins <br /> pectionInspection Type (Fill one) <br /> Site Suffix: , S �J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Oaf (�(,(�� C Bzt Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected B <br /> P Y Inspector <br /> LAu_I4/jO& SI e t�el�t JJ_ �►c• I _ <br /> Physical Addr6ss G' <br /> L-3(l ZePh� <br /> Street <br /> Inspection Date <br /> City State Z;?Code Time In Time Out _ <br /> Business Rep Title ) 0 AM /�I r—IQ AIN <br /> �e BPM 1 (J! ' : ' !�� ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tlfe Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that appy) <br /> t f ® Active ® Passenger ® Generator ® Outdoor <br /> i O Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> - - Q Inactive ®Truck <br /> Longitude - i 'O Q Planned I& 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 /> 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 NhSTrVzn0PL f�OrYIpQ�L <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V AHAULINANDM <br /> G ANIFEST REQUIREMENTS <br /> Q Notice Of Violation <br /> Q Q Q Extension <br /> 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 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or DCT) <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 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 Q1 Other: §. 'c ,j,, /- <br /> Comments r1Qu� l�q,_ /��.7—C -�-,f� •T�Uc. �L'o__ 7 QN Lt <br /> 1�les✓t/r�.h.h oil V�1 ."�r � r_vf C� G� o C7ZMA'�es <br /> M15 uky�e ,, Ie- ela ;Vie .¢ eK ` ltf frltcks [AA f Y�— <br /> t�-a�l�,rs_ h FavL mo <br /> Inspection Form Included: Q <br /> Comments Included: Q tog 51411-joy-L . <br /> gusine§1(lep'44ignature Phone Number Inspe915rs Signature Phone Number <br /> INSTRUCTIONS ON BACK C rrec Incorrect: X A P ;L E . 111213 62081 <br /> White Co .CIW Yellow Copy.Operator Pink Copy.LEA ® . <br />