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Waste Tire <br /> SuSey & Inspection ReporWrispection Report Number <br /> MI: State of California ■ <br /> CIWMB 181 <br /> (New04104) <br /> California Integrated Waste Management Board Survey Form - Page 1 1088183 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site <br /> D Ll L4 :__2� <br /> Suffix: I <br /> ® Routine 0 Re-inspection 0 Referral 0Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Cl --7cj,19 U I n C 0 U V') 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> '-_C <br /> Physical Address -39 t 1 9 <br /> n Lu r4 <br /> L <br /> I'll <br /> (A r-n an Inspection <br /> Street Date 7 <br /> -::>+C)r-�<'to n <br /> City State ZIP Code- Time In Time Out <br /> 0 AM 0 AM <br /> 0 PM 0 PM <br /> 'Fq ---------- - <br /> Business Rep Title <br /> I ot I kA�i Hcf - <br /> Operational Status tire Type Business Role rStorage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> * Active 0 Passenger I@ Generator 0 Outdoor <br /> =1---TF1 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> li-E 10 0 Inactive 0 Truck <br /> r T­F— <br /> Longitude 1 0 Planned 0 OTR 1 0 End-Use 0 Container <br /> Business Type (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 Other it 1 on .-C,eAter <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 7 / FT] / m0 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 <br /> 0 in Compliance - No Violations <br /> 10 0 Other: § <br /> Comments <br /> jo�__ �P�, io�a 7te 7%4 �0110wllria L,)Gs <br /> rX C—I �ty uses 7t n C.1 r.,Cl _X Cl d cA-S�( 1 1 T'l rp- or <br /> ,fyo Ire17 N/I C R_ _z 0 V ct cna') ac� e d cifed (:_)z_1/0-7 ku Qe <br /> L4 (i <br /> /o L <br /> �, ,Ve b-,Cen T__e ci I T-�-Qd Wye <br /> Inspection Form Included: O <br /> Comments Included: 0 <br /> Busir_,ss Rep's 5ignalure Phone Number e,''. hone Number <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X V X A M Pa <br /> -t-l-ri -1 31 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />