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Waste Tire SAley & Inspection Re oro Inspection Report Number <br /> ■ '' State pf California h 1— ■ <br /> ®Ate CIWMB 181(New 04/04) TT 1 �0 R (��y <br /> California Integrated Waste Management Board Survey Form - Page 1 J+ + _ °� °-+ `� o <br /> Part_A- Survey___ BLUE OR BLACK INK PEN <br /> BusinessProfile Inspection Details <br />( TPID- Lo <br /> �� - ��.. _ �_�I Inspection Type (Fill one) <br /> Site Suffix: --� J ® Routine 0 Re inspection Referral 0 Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> �J C7 rl To':� l�1 n �..�J rlI Y? 1 <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 G <br /> Z G 2-- 1- b Y -A- Y) <br /> ,Street <br /> Inspection Date 5__9L4._ / <br /> cA <br /> City i State ZIP Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> I I F'Gr>�I� LaY M_ r . <br /> --.� ; Q PMm1glaii i;i; [a] [-- -- O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 9 Active 0 Passenger ) Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude -� _7 0 Hauler 0 Indoor, ,0 0 Inactive 0 TruckLongitude - 7711 1 d 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body (M Car Dealer 0 Collection 0 Crumb Rubber <br /> Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS - <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 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 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § L.-- <br /> Comments ( c <br /> iyi` r— Ir - i' CA'i Cwt T0IrP GE -A' )_ �ciiE � ��1Q `T� �IUWInq r"ITi✓CI_' <br /> J I <br /> N\r'_AE t-C- - , scored ar-,- )ie -+I" A ',r, P'e'-t In Fr,c►�i�J a u e C�lliI (irnl _r <br /> T I f'- M"f : Q l_ti _ n-)V G� . C-T L I <br /> �,� <br /> Inspection Form Included. <br /> Comments Included 01 <br /> Business Rep's Signature Phone NumberIpcs Signature '" Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X �,. A M L 3 <br /> ■ ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA � <br />