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■ Waste Tire StAky & Inspection Report Inspection Report Number t <br /> State California I y - 1088231 <br /> CIWMBB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board - <br /> Part A- Survey _ _ BLUE OR BLACK INK PEN <br /> Business;Profile Inspection Details <br /> Site - ' 1� — — —� W Inspection Type (Fill one) <br /> Site Suffix Ls� <br /> ® Routine O Re-inspection O Referral O Observation <br /> Local -t- If Referral,choose referral type(Fill one) <br /> Identifier: on 1 `�G o q u 1 Y C G!rI �j 0 CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector t <br /> T L r t'c k �,. i--- -- — <br /> _ _ _- J L:� <br /> _ LLLPhysical Address _.v__._.___.._�__.�T—. I __� <br /> Street <br /> Inspection DateI e)] F <br /> -T:�Zok-_� — )] -Mql�_ <br /> Time In Time Out <br /> y State ZIP Cade <br /> Business Rep TitleO AM O AM <br /> L - O PM O PM <br /> Operational Status Tire Type " Business Role Storage Ty <br /> (Fill one only) (Fill all that app „) (Fill all that apply) (Fill all hat ap�1 <br /> 1 ® Active 0 Passenge` ,, � Generator (� Outdoor <br /> LL �� �- �- O O Closed O Altered <br /> GPS Latitude O Hauler OIndoor <br /> , <br /> --�---_ 0 Inactive 0 Truck <br /> Longitude - Q End-Use Q Container <br /> g I 999 Planned. OTR <br /> Business Type (Fill all that apply)'` <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government Q Retreader 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> O Service Station Q Hauler O Agriculture Q Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -- -- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O <br /> 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 <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 Q Referred I 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 <br /> In Compliance - No Violations <br /> O O Other: § -- <br /> Comments �OU��t12 1nSGftC�" Gr> f35zr rvrrrA'.(l 41 d�e � kt �70I 0W In6- w -1 <br /> \Y C',, '�t6reC1 or,- _ 1 �-e . Fctctlt �;► °A:._ <br /> G CA (At r. t t='roa,_I ct:�: , ='mac.. -}-o rif►rc,ovQ W a z-A -,-)rro,rr) pre r)), <br /> `V0r.I two Liz Ir t—aG��I�,I t' � C �'1 t 1/C 1 SOW JGAU mr :)-en C cqior. <br /> ,Inspection Form Included <br /> p w' <br /> Comments Included � � <br /> _- <br /> usrness Rep's Signator Phone NumberInsp c'to"r's Signature' ,r <br /> ;�' 62081 <br /> INSTRUCTIONS`ON BACK Correct: Incorrect: , l P N I 3 <br /> X _ �______..0._00 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />