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Waste Tire Suf6y & Inspection Rep®r Inspection Report Number <br /> *aS § State of California <br /> �4 CIWMB 181(New04/04) 1127628 <br /> 4/04) Survey Form - Page 1 I �. 212 7 6 2 8 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br />} TPID- Inspection Type (Fill one) <br /> A_ <br /> Site Suffix: i ©� f - LQ I j Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ? If Referral,choose referral type(Fill one) <br /> T Identifier. I <br /> v 4 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V UInspected By Inspector <br /> Physical Address i <br /> ,1 11 lo 1 1 <br /> L\_J_ <br /> z- <br /> _.._.._..__._..._.. .._...__ .... _ ..._..v......._... .. _............................. <br /> �treei <br /> Inspection Date 10171 i 7 ra C' .�J'� .__. 7-) LFq1 <br /> Stat: ZIP ;ode Time InTime Out <br /> Business Rep Title ._ AM <br /> AM <br /> o PM O PM <br /> t ..._.__....__ - <br /> �q a� <br /> . Operational Status Tire Types Business Role Storage Type <br /> The Cf3aint{Whole�PTE} t (Fill one only) (Fill all that apply) (Fill all that apply) (Ril all that_apply) <br /> tr � 0 9 0 <br /> �z� Active i'a on PI Generator 0 10titd(?o• <br /> Latitude 1 D Closed 0 Altered <br /> GPS - 0 Hauler 0 indoor <br /> —� ~~~ 0 Inactive 0 ruck <br /> Longitude <br /> g _ ( i 0 Planned 0 End-Use 0 conta�n,er <br /> BusinessType (Fill all that apply) ` ...... _ <br /> 0 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 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 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 M 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Datem / m <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 0 In Compliance - No Violations <br /> 0 0 Other: <br /> Comments , t, ¢41't �7( <br /> dF-had s wife- o>r. le fiiros from sir <br /> W& 0ewed . 071, maniresl Mi <br /> r e _ <br /> Inspection Form IitCiuded: 0 <br /> Comments` Include: 0 <br /> - Business Rap's Signature Phone Number inspectoe s.5iq�iature Phone Nt tuber <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �,A , � 'P i 1 5208'i <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />