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Waste Tire Sp y & Inspection RepossInspection Report Number <br /> L6A3�so State of California a ' r j �r <br /> CIWMB 181(New 04/04) Survey Form -Page 1 - =� _ - <br /> California Integrated Waste Management Board S ; t <br /> Part A- Survey _ —_ -_-. <br /> _ — - - BL <br /> UE OR BLACKINK PEN <br /> Business Pro!I 7, Inspection Details <br />} TPID- inspection inspection Type (Fill one) <br /> Site Suffix: <br /> L t] (3v Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: _-r lr 1 - t��� F <br /> 1 / Q CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> ?tet. .t 4 <br /> Physical Address <br /> r <br /> Street <br /> Inspection Date / [P-1 <br /> I � _Cl____�_. State Time In _.._._.. Time Out <br /> �J <br /> I tyr 1P Code <br /> Business Rep Title7, o PM O PM <br /> Operational Status r Business Role <br /> (Fill one only) ( I f (Fill all that apply)ON <br /> ( I ' <br /> ® Active O Generator 0 Ouid0 <br /> Closed Al <br /> GPS Latitude O Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Q End-Use 0 Container <br /> Longitude - � O Planned Q OTR <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body O Car Dealer O Collection O Crumb Rubber <br /> I <br /> 10 Service Station O Hauler O Agriculture Q Shredder ® 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 /> O Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FF1 / m / O <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> O O Other: § -- - -.. -- <br /> Comments —4--p-AC) <br /> kl r t U1G3 <br /> l e< SCS ar 1-rucV. — Aro. <br /> epi _( V i -lea=� �2� 1`� S -- C�l�_L} 1 _ c, �0\II -- <br />} <br /> .Inspection Form Included <br /> 5• � ;r Ali � � r� �� ts nc " r " <br /> Comments Included.-} - — - =- <br /> Business Rep's Signature " P one Number - 1 - -ors <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X ' W A: f' r3 <br /> % ■■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA. - <br />