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__ Inspection Report Number <br /> Waste Tire Survey & Inspection Report ■ <br /> >.:. <br /> rp Slate of California <br /> Cf"B181(New04f04) Survey Form - Page 1 -1 4 -- 1 0 13 7 9 6 <br /> California Integrated waste Management Board - <br /> Part A- Survey _ BLUEC f3_ L A�K1K PEN <br /> Business Profile Inspection Details <br /> TPID- i O 2 pl`'f 1317 .Inspection Type (Fill one) <br /> Site Suffix: VULL <br /> fix: 1 J 1111 1 a Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name SJe V Inspected By Inspector <br /> Physical Address <br /> 5161 41 m and woA T i <br /> Street <br /> �Gu/ /•►,/l/t� 15 3 3'� Inspection Date <br /> AOut <br /> ) t^� <br /> ,ty �nre Zip Code Time In Time Out <br /> Business Rep Title ul : �OO FM M : = <br /> AM <br /> QPM <br /> �Y CPi S - - -"-— 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 /> Tire Count(Whole/PTE) 3. <br /> �' ' ®Active Q Passenger 4D Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q 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 Q Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other Layl� <br /> Part B-Inspection of Waste Tire Dealer, Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V { 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-RegistrationlDecal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q 10 1 Other: § _ <br /> Comments Rc1- AZs da t e� fi!t _ ,Wc J n Ar If <br /> has _ }� �on 0/10/0&. <br /> -f'G>�twie 'lf de�� s�Pa <br /> In e __fir t CttkX$ ad Oce, faAfcL <br /> On io)ff, pripac ot^d mg I,c)&ey' Ins <br /> Inspection Form Included: Q p/ <br /> Comments Included: ® - <br /> Busi es Rep's SignUature Phone Number In pector' Signature Phone Number <br /> �-�( 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � l�.J X A �A P L 11121 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br />