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M T <br /> Report Number <br /> Waste Tire Survey & Inspection Report Inspection Re P <br /> -� Lupi State of California <br /> = cIWMB181(Now 04104) Survey Form - Page 1 ! 6 - 10 13 6 0 0 <br /> califomialntogratedWaste Management Board BLUE Op W Sr" EN <br /> PartA- Survey _- -- <br /> Business Profile Inspection Details _(� 0-5000 <br /> TPIDInspection Type (Fill one) <br /> Site Suffix; 141 _r TOO 0 Routine Q Re inspection Q Referral Q Observation <br /> -( H <br /> Local H Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �- �.s <br /> - <br /> Physical Address 5T-OL, <br /> Street Inspection DateU =C) GC4 9S2D� Time Out <br /> III ��� III ( <br /> ( — Stat-o 11}'� Time In <br /> Gty ET <br /> AM <br /> Business Rep Title 1 : O PM L t� qM LE-1 : <br /> � <br /> -1 0 PM <br /> /" 4rk co` __ _ _ T"', 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(WholelPTE) 1 <br /> ®Active Q Passenger �Generator Q Outdoor <br /> — — - O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> _--- - D Q Inactive ®Truck <br /> Longitude - Q Planned 1 Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) - <br /> Q New Tire Dealer p Auto Repair ®Trucking Fleet p Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler Q Agriculture Q Shredder Q Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS_—_ <br /> V A 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-Registration/Decal in Vehicle <br /> Q (D 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days -- <br /> Q O 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 f 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 0 Other. § --- -- - - -- -- -- — — <br /> ! ' &QU nQ _;L4.ems? <br /> Comments 0"4- I/„c•,/y di r ��'- <br /> 1 15 Dgt4 Es�-es /'I(�Ci- _�-�r•����`�--- - - �4albi • <br /> I r Z _ 9ds Gtr`c V i Ce _ �_ �__�—C k�. " <br /> QrtQ—�.-_��- tree ✓'� � _(3(0-� _ S a'r ��� �r <br /> Inspection Form Included: QG� 1(�� <br /> Comments Included: ® Business R p's !gn re one Number 1 s ctor, Ignature ��umber <br /> — 62081 <br /> INSTRUCTIONS ON BACK Correc . Incorrect: (( E X R M P L P 12 3 <br /> . White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />