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Inspection Report Number <br /> A Waste Tire Survey & Inspection Report <br /> itml <br /> kaState of California <br /> CIWMB181(New04104) Survey Form - Page 1 Il - 1088444 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � � � _ � ! Inspection Type (Fill one) <br /> Site Suffix: 3 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: � \qy) l �L�() 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name v" _ <br /> �� ..� Inspected By Inspector <br /> Physical Ad r�ss V , &0 F'5 CA <br /> 1 on GA �5 3a� Inspection Date 5 <br /> Time In Time Out <br /> Business Rep Title ( 0 AM L 0 AM <br /> n`�" t 0 PM a 1 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) F (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J 16 Active 0 Passenger f) Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive ®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 i HAULING AND MANIFEST REQUIREMENTS 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 <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV orEXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years I " <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 . In Compliance - No Violations <br /> 10 0 Other: § <br /> - <br /> Comments �>) nL `t n��- �U n ` t 1S and. - o�,.n was oa-, <br /> li*,%o v OV�N\t clo� o a c.On <br /> T'44c'- t , CtC.l Lt�S vvl`5b� �LA. i�c� 0.S 1�121C �c ���cl� �. �[' fyl(4f, <br /> Inspection Form Included: 0 �L�����iV I (�6 <br /> 61q <br /> V3 <br /> Comments Included: 0 <br /> Business Rjr;rect: <br /> ature Phone Number &InspeVc -Migonatre ne Number <br /> INSTRUCTIONS ON BACK correct:Xlfi EXAMPIL E 1 2 3 <br /> ' T f� I6208, <br /> Whde M Yellow Copy:Operator Pink Copy LEA <br />