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Lfi's. <br /> Waste Tire Su► ;y & Inspection Report nspection Report Number <br /> ttS.c State of CaliforniaC WB 181 <br /> California In egrated Was eeManagementBoard Survey Form - Page 1 1 T 1 <br /> 04/04) <br /> 1 1141027 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile i Inspection Details <br /> TPID- 1 ` I Inspection Type (Fill one) <br /> Site Suffix: b © ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCS C,4 , , 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> -- - -- <br /> Business or Facility Name Inspected By Inspector <br /> jc'— rnC, . <br /> Physical Address 3 - 0 <br /> Inspection Date 0 O 0 <br /> L�cl; Ca'� �t�2-qo <br /> Time In Time Out <br /> Business Rep Title ) _ 0 AM 0 AM <br /> i C 'Z -3 5 ® PM 0 __2 y ® PM <br /> -1 Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger ® Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 4P Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ._._...... 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers, Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / FU 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 1 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities { <br /> 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments l <br /> Q�/fid�1�LR�t-YNS-�C rt�"�+ �pyY�--1 - �L�. (�CCtA- lv�C( ` (/`Q <br /> �"D_L1.L.7_]GY(• W�iS__. . Y�V IC.CJ` •. _ __-- _ _ _ ._ <br /> Inspection Form Included: 0 <br /> Comments Included: 91 <br /> - Busi P,s, Sia ;fur. Phone Number nspector's Signature Phone Number_ <br /> INSTRUCTIONS ON BACK Correct: Incorrect: XIS";. _ 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop <br />