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Inspection Report Number <br /> Waste Tire Su6y & Inspection Report <br /> � C State of California I 1 - 1088181 <br /> 7,4CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part <br /> i <br /> Business Profile � "' "� - -- _ � ;, Inspection Details BLUE-OR BLACK INK PEN <br /> TPID- Inspection Inspection Type (Fill one) <br /> —7 <br /> Site Suffix: 3 1 Z �2.� J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local1 If Referral,choose referral type(Fill one) <br /> Identifier: Grl �O Q CA I'0 C CSU CI 1 k <br /> i Q CHP Q CIWMB, Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addr —� 0 <br /> I lir t tit►G rl LcaSS;S E i <br /> s 1 • yy <br /> Inspection Date [0 <br /> _ p <br /> CA 9 5 w6 j <br /> Cir State _ ZC�'Code Time In _ Time Out _ <br /> Business Rep Title _T_1 <br /> 1 0 AM 0 AM <br /> L-1 I :� ' O PM � O PM <br /> Cz ma c e r M u r I� t �ct n c. c- e_'fa <br /> ' .....1° Operational Status Tire Type Business Role Storage Type <br /> "'' " '"' ' ' '" Fill one only) Fill all that apply): Fill all that apply) <br /> (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> ( y) ( pp y) ( pp Y)' <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> ered <br /> D Q Closed Q Alt <br /> dGPS Latitude � Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - ~� —O <br /> � ^ — <br /> g 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 Q Hauler Q Agriculture Q Shredder % Other —70 <br /> uU In r, <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A j 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 Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements DateM / m / 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 EXT) <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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> GuA hS �r QecAIon d C\cAtc <br /> �o'CC� Fac.\�_ �-t-►- C -T ti fe I��c r�- car �c�`te -tire _-e,rn ovA - <br /> i <br /> GTL. v,,_cAA'I _Q ts o a 7 "19 2.005 t..j eYCL aTv <br /> dca�� c, ,� or v�e+vtr�j. <br /> I <br /> Inspection Farm included: Q ✓s M1 r / <br /> Comments Included: - c x <br /> Q Business Rep's.Signature Phone Number Ins p ttir s Signature y;° Phone Number <br /> - - - / L._. 62081 - <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 1 V I M11P I L e [112131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />