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` a Waste Tire SL&y & Inspection Repor� 'nspection Report Number <br /> State <br /> CIWMBf 81(Nrnia Survey Form - Page 1 1 8 - 1 0 7 9 3 7 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- SurYM— - BLUE OR BLACK_ INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' - r Inspection Type (Fill one) <br /> Site Suffix: © r y 7 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local > If Referral,choose referral type(Fill one) <br /> Identifier: SG2/Lq G eca jv Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name C� Inspected By Inspector <br /> Physical Address <br /> 3-9 7 4�z-,4-e Ae- <br /> Inspection Date / 6� v0 162 <br /> Time In Time Out <br /> Business Rep I �i� Title //rs ® n n ® AM 'y * AM <br /> 1�C 04 `N C - - G �O 0 PM- D-7 -2 © 0 PM- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude _ Q Hauler Q Indoor <br /> p Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> L New Tire Dealer ® 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility j ENFORCEMENT STATUS <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <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 F_XT) <br /> O O ----- -- --------- ---------- - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> O Other: § <br /> Comments `/40� .e o�✓, o L�/� lii6-14'x' <br /> Ate° w r� /17 <br /> d�.�'`.t✓yyS^� ,�. <br /> ofz, . <br /> Inspection Form Included: Ui� <br /> �, <br /> Y <br /> Comments Included: - - - - — - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Core t: Incorrect: X y, FCTA-,,Ml P I L I E T1T2 3 <br /> White Copy: IW Yellow Copy:Operator Pink Copy:LEA <br />