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Report Number <br /> � . .^ Inspection w . Waste Tire Spy & Inspection Repor p _ � <br /> State of California <br /> CIWMB 181(New 04104) Survey o I # i <br /> F rm - Pa g e1 . i <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A Survey <br /> �'Inspectioh Details <br /> Busm ',P <br /> esro#ale <br /> (� — Inspection Type (Fill one) <br /> Site Suffix: L061� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��C7tTr 7C �I1. n �U(_,Ani Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical-Address L91 O <br /> Street <br /> Inspection Date <br /> Time In _ Time Out <br /> r�, State Ztf�Code <br /> Business Rep Title OAM r O AM <br /> Tit-(`(i 1 (�C,ki � �,- O PM d.�� �,-,_.__.._ - O PM <br /> t-'' •l t'� '' ' ? —� _ _- <br /> Business RoleStorage Type <br /> Operational Status Tire <br /> ( one only) (Fill ll all that apply) ( althtppI <br /> Y) <br /> Tire Count (Whole/PTE) <br /> Q Active 0 Passenger (S Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude y d g Q Hauler Q Indoor <br /> L-L-__1 L.___ #.��_.__i --�.--- Q Inactive Q Truck <br /> Rude ' --- 1 F o - Q Q End-Use Q Container <br /> Lon <br /> 'Business Type (F"Iil elf'tfr�`a Q Planned OTR <br /> Q New Tire Dealer Q Auto Repair 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 C <br /> '00.17L42-r-/b pex�itsr--.-... <br /> Part B----Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityL 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive.TripiLogs Vithin 90 days (Required for NOV or EXT <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive.,firipiogs f 3 years % <br /> Requirements Q Referred/CIWMB EnforcementQ Q 14 CCR§18460.2-Manifest System oRellstered Waste Tire Haulers <br /> 0014 CCR 18461 -Manifest stem Requirements for Waldte <br /> Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> Comments (� <br /> 0 <br /> l�01 j ev)�C r� C7: - <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number _ Ittspector•s Signature Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X `, s j AA P,11,L C <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />