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LYY <br /> ILM <br /> WasteT8re Survey Inspection Report- <br /> State of California ep�,s� p��y� �ay� `f$f -J'1¢ <br /> CM/MB 181(New 04104) u l'°Y e� ®b'°I E II ® Page 1 ( � 1 '•f 1 �+ 396 <br /> Calffomia Integrated Waste Management Board. `� <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile ( Inspection Details <br /> TPID- Inspection Type (Pili one) <br /> Site Suffix: Z [�il ®Routine Q Re-inspection <br /> ection Q Referral Q Observation <br /> �Gj <br /> Local If Referral,choose referral type(Fill one) <br /> identifier: � w"#7 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name j/•- Inspected By Inspector <br /> Physical Address l D <br /> I— t-f- <br /> Street 1 ' <br /> Inspection Date 1 C� <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title : OPM E :m O PM <br /> OperationalFU <br /> StatusTire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) ' 1 <br /> (8 Active ® Passenger Q Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude i ©Hauler Q indoor <br /> O Q Inactive Q Truck <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 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 a Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility. ENFORCEMENT STATUS <br /> V 1 A ;HAULING AND MANIFEST REQUIREMENTS ®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 f PT� I FQ Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2"1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or E>(T)--- <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> ® Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 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 /> Comment� �.--�v.�Vr `ii/�..e.�_L,�_S GVu�Jo,��JL � (✓��+�,--t �/I�C?..�g�-D_i�+TC.� <br /> Inspection Form Included: ® ' — <br /> Comments included: ® — 46 <br /> Number I <br /> Business Rep's Signature Phone Nnspe is Signature Phone Number <br /> ' <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ( RX A Nt P L f 62081 2 3 ■ <br /> ® While Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />