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Waste Tire SurV & Inspection Re ort' Spection Report Number <br /> �/ p p <br /> State of California <br /> SurveyForm - Page 1 Il 1088010 <br /> CIWMB 181(New 04/04) � — <br /> C•alifornia Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile r �� f'i' i`q'� `r` :Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix. Routine Re-inspection Referral Observation <br /> � o � 2 7 y� � ' ��._� ® o P o o �I <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: '{ 1 C <br /> 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address t\LAtO 1 <br /> nt.� C LO d <br /> s _ <br /> z, IE F�1 YLQ <br /> Street _---- _ <br /> r Inspection Date <br /> c-A q 2_q o , <br /> Time In Time Out <br /> Bust _ uu state Zl�'Code _._-._.__ _.--_ <br /> Hess Rep Title ` 0 AM O AM <br /> 1 f� QPM [= : FQPM <br /> miimkim. <br /> fin Storage Typep yp Fill all that a I Fill all that a IO erational Status lire T e Business Role(Fill one only) (Fill all that appiY)'i ( PP Y) ( PP Y) <br /> ®Active Q Passenger, ® Generator Q Outdoor <br /> - O <br /> Latitude Q Closed Q Altered <br /> GPS -_ .T Q Hauler Q Indoor <br /> _ <br /> T— _ —_ Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR o 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 (p) 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 ENFORCEMENT STATUS <br /> V <br /> 71 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 m <br /> Q o 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements i Date <br /> 010 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q o 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q o 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 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 /> Q o Other: § c- <br /> Comments Ou nQ IYIS(Z2C tnn Pr�TorrncA -+lL, t +f cnA -*,e --1(_AGt r`, <br /> C C, ►I _T if9- a\ -hof t-oa�tAe -t v-rz. <br /> (-e m as Q, " ,r ct rn D Y_e m I 2�: . C-1 L rf)GCn&_,}<. �n Gv e- �,EGY) rz�(O YL-e d c xy)� L1;,_ <br /> of ;i'.�� 1t� 1 1 ,(11 rn�)/ f_". n f1 % �01It)r fL`cktl ' -05� GC�C.Cj <br /> +nspection Form Included: Q <br /> Comments Included. 01 /•. . - "t.t ":� f ,a� ;.. �lti ` l <br /> Business Rep's SignaturePhone Number In1se�tor's Signature Thane Number <br /> _ - <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X Jam, � �X �dW'id E; � 62os1 <br /> White Copy:CIWMB Yellow Copy:OperatorPink Copy:LEA <br />