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Inspection Report Number <br /> Waste Tire Survey & Inspection Report ■ <br /> _ , State of California <br /> Il - 1143992 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey - <br /> IBus-iness Profile Inspection Details <br /> TPID- ! 1--- _ <br /> Inspection Type (Fill one) <br /> Site Suffix: I r to � 01 <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 /'� _„ . If Referral,choose referral type(Fill one) <br /> Identifier: L C_C>L Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business ornFacility <br /> �N-ame i,- Inspected By Inspector <br /> — <br /> PhysicalAddressl 11w1'V)�GY� i /Tlj�iY1S� An rnbolc` <br /> /�� Inspection Date <br /> q«06 Time In Time Out <br /> Business Rep Title ® AM lne AM <br /> _ 7 <br /> OPM_ � GL Y OPM � <br /> V l�( t1\�� 1ICtiC�dl ►u J - -- <br /> Operational Status <br /> Tire Type Business Role it Storage <br /> Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 9 <br /> er Q Active Q Passenger Q Generator Q Outdoor <br /> — O ® Closed Q Altered HIS NIA <br /> GpS Latitude NtA Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR <br /> 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 ® Hauler Q 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 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 / <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT)Q <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 Q Other: § - <br /> Comments 7_ <br /> pL t�-61--Ai3 I,%-. ,�� lcrn�✓_ /z 4-1)? .- <br /> �L-f �3—�C�cs Alec,,,J <br /> - .t! rvtwtrvtt <br /> 20 <br /> Inspection Form Included: Qii <br /> ✓' l �Y 1 <br /> Comments Included: Q a1 -- - - -- - - I ctor_s n ureP Nne umber <br /> 3 <br /> Business p.s S na re Phone N mber P 9 <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X <br /> - - -- ® <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C ■y' <br />