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Waste Tire Survey & Inspection Resort Inspection Report Number <br /> aLal State of California <br /> • CIWMB181(New 04104) Survey Form - Page 1 Il - 1088456 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection Inspection Type (Fill one) <br /> Site Suffix: ` 6 L 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local n /` If Referral,choose referral type(Fill one) <br /> Identifier: � l WIJ� � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name _ Inspected By Inspector <br /> Physical Address 5 12�1.�G f m&k <br /> Oleroyiec- Lei . <br /> Inspection Date O / v Cl <br /> L CCA <br /> Time In Time Out <br /> Business Rep Title /t- O AM Z. O AM <br /> ® PM � L -� ® PM <br /> �iC.�lctrC� Mct�lc�fU�'►'1 Qc�rr. <br /> V Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' <br /> 0 Active 0 Passenger 0 Generator ® Outdoor <br /> D 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAiiUNG AND MANIFEST REQUIREMENTS <br /> 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 /> 10 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / / M <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 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 LV <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 /> in Compliance - No Violations <br /> 0 0 Other <br /> Commentsgux me, lyi1 ,p�'C h-t� '� Omit, ori I fIt S C CLre C rib 4� TU�I�t)!,Y7 <br /> �7�1u1-►2;y)s or Ayrus c4- Concer�I <br /> dote Gcc,k� rvr� Mefcvf�� �� �r�� Users C.Ja�� Recc;v��c� '�fir <br /> i <br /> _V, dY�t,-thy Ckre- y7i w asIlc,� <br /> Inspection Form Included: 0 4 <br /> 3) % <br /> 7 3 <br /> Comments Included: 0 <br /> lust nesssep's Si nature �Shonfe <br /> Number Inspe or' S' nature Phone Number <br /> i N 62081 <br /> INSTRUCTIONS ON BACK z7v <br /> Incorrect: X E=X A �L E 1 2 3 <br /> While Yellow Copy.Operator Pink Copy:LEA <br />