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Waste LOW& inspection Rio "pegtion-Report-Number <br /> ■ - --- - - <br /> State of California 1 1 1 ; 3 I 1 4 3 <br /> CIWMB 181(New 04/04) Survey Form Page -V. V <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey mommommognmoo- <br /> Business Profile NN_01 <br /> �m�„ . <br /> TPID- -� Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection Q Referral Q Observation <br /> Local {� � } If Referral,choose referral type(Fill one) <br /> - <br /> t) t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Identifier: <br /> Business or Facility Name Inspected By Inspector L31AI 11 <br /> • <br /> I <br /> Physical Address i,' �Ll <br /> �7. <br /> Street `- r Inspection Date 161161 <br /> fe l Time In Time Out <br /> City State ZIP Cod <br /> Business Rep Title E-E-1 : F J M L__LJ <br /> O AM O AM <br /> _----?r_ (r• ` �.• �' Operational Status that a <br /> Tire Type Business ole Storageill all that <br /> y apply) <br /> (Fill one only) (Fill all that apply) (Fill all apply) <br /> Tire Count(Whole/PTE) ) Active Q Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS. Latitude • Q Hauler Q Indoor ' <br /> O Q Inactive Q Truck <br /> Q End-Use Q Container <br /> Longitude — , Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q New Tire Dealer Q <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> i r' <br /> Q Service Station Q Hauler Q Agriculture Q Shredder (a Other T. F V <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 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 <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / FTI / M <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - <br /> 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 t {r ✓) ' - <br /> r # kCr rJ� i! f ; r �G I�0 1t1 J ki, <br /> l . ; — <br /> Inspection Form Included: <br /> Q,' <br /> Comments Included: 0 Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />