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00363050009 <br /> r= Waste Tire- Su&y A.Inspection ReporAI Inspection Report-Number <br /> erc. <br /> Stateof Califomla <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I 1 11275 0 6 <br /> California Integrated Waste Management Board <br /> Part A-Survey: BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> TPID- � InspectionType (Fill-in <br /> Site Suffix: k 5 O C 0Routine Re-inspection Q Referral Q <br /> Observation <br /> Local /!� If Referral,choose referral type(Fill one) <br /> Identifier: � >� Wa. Q CHP Q CIWMB Q Complaint• Q Educational Visit Q Other <br /> Business or Facility Name <br /> _ Inspected By Inspector <br /> Physics Address 3 ` O l L A=v' <br /> 91 -moi <br /> M <br /> [o::1Y <br /> Inspection DateT <br /> StreetTime In Time Out <br /> City l Slate ZIP Coda _ <br /> Business Rep Title 11 O AM 0 AM <br /> I_(,J_�J •L��� J PM IZ , A PM <br /> Operational Status :Tire Type Business Role StorageType <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f <br /> ®Active ® Passenger • a Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude f •1 i I i Q Hauler Q'Indoor <br /> O Q Inactive 0.Truck <br /> Longitude Q Planned Q OTR 0 End-Use Q Container. <br /> I •L __ _ <br /> Business Type (Fill all that apply) <br /> New Tire Dealer - Q Auto Repair Q Trucking.Fleet • .Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ®•Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B!..Inspection of Waste Tire Dealer, Generator,Hauler and End-Use FacilityENFORCEMENT S1TATiUS <br /> V A HAULING AND <br /> M AN I I.E SITJ REQUIREMENTS <br /> Q 0Q Notice`Of Violation 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 m m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NO.V'or, <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/CtV11MB Enforcement <br /> Q 0 . 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In.Compliance - NoViolations <br /> 0 0 Other: § ---- -- -- <br /> Comments <br /> Inspection Form"Included: Q <br /> 011 <br /> Comments Included: — — - 36^ l �enuuBusiness Rep's Signature• Phone Number . 'Ins ' rs Phone Number: <br /> ,� "° f 62081 <br /> INSTRUCTIONS ON BACK • Corr t: correct: P L E 2' 2 3 <br /> White Copy: IW Yellow Copy:Operator Pink Copy:LEA ®• ' <br />