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8d <br /> Waste Tire S ey & Inspection Repor� Inspection Report <br /> Number <br /> State a � <br /> CIWMB 181(New nage) Survey Form Page 1 Il - 1088295 <br /> California Integrated Waste Management Board g -.. ..-. -... <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile _Inspection Details <br /> --- <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: y q I'� { J L' t ® Routine Q Re-inspection Q Referral Q Observation <br /> Local r III��� i_�_)W' <br /> If Referral,choose referral type(Fill one) <br /> Identifier: `i U Ci i.it I1 (` c�,..l(�+..{ <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> - ! n ►reg — _ E' rGkes _ <br /> Physical Address � � <br /> LG j Kr ! _1-!unLLA CG_�� <br /> 1 1-1 -7 N1�ar ��; <br /> Street lj�] <br /> 1_Ca�-hrp Inspection Date <br /> arty �p i--` State ZIP Cod I Time In Time OutAM <br /> _ <br /> Business Rep TitleLi <br /> .-.._._.. PM F <br /> - ..-�—� 1--f ®AM <br /> 0 PM <br /> ►s.._ --G LaY� n n o C7 0n r... B- g <br /> v� , -- --t er. <br /> Operational Status Tire Type Business Role Storage Type <br /> I I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> NOISE] 0 Active Q Passenger Q Generator Q Outdoor <br /> J .1-11 <br /> .EE =1 <br /> pQClosed Q Altered <br /> GPSLatitude Q Hauler Q Indoor <br /> 'O Q Inactive Q Truck ; <br /> Q Planned Q OTR <br /> Longitude ( Q End-Use Q Container <br /> g 1 <br /> - � <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 /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> QService Station QHauler <br /> Q Agriculture Q Shredder Q Other I "�-w--.-..-.,-,_r....,.,,.., . ��z^•"-"" <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / IE / IE <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 ® In Compliance - No Violations <br /> Q Q Other: § — -- ---- - <br /> Comments <br /> cautp- <br /> -�Ja� 'oC+2CX A praK . 51_ +o4 (;1 't re ­e{6 <br /> 39 ,j ck� )r `--I �� ec�- _ t ►Ye� F^ �GI1iI� , carr n _�� e MLZT <br /> - tV LT <br /> - <br /> his ection Form Inc!udei Q <br /> Comments inclIusded. 0: <br /> Business R , <br /> ep s Signature Phone Number Inspector's Signature Phone Number <br /> _.�.I__-_. 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: b-^= A OV, I- f, t �V R <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />