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Waste Tire Su:- - Joy & Inspection Report inspection Report Number ■ <br /> �tfl State of California <br /> CIWMB 181 04/04) <br /> California Integrated Was eeManagement Board Survey Form - Page 1 Il - 1143648 <br /> PartA-Survey._ BLUE OR BLACK_ INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> ) � n <br /> Site Suffix: t "b 6 t 6 ` I t 0 I • Routine 0 Re-inspection Q Referral 0 Observation <br /> Local C ,, 1 If Referral,choose referral type(Fill one) <br /> Identifier: �tLV� �C.I {y�J1i,1V�, O CHP Q CIWMB Q Complaint Q Educational Visit O Other <br /> Business or Facility Name 1111 Inspected By Inspector <br /> Physical Ad t ss — i c) At6r [.__X� ��mI-E�o,c, <br /> Cu.] (3k t�.�i 0 r�l,iif't ty c v I V'c <br /> L"� <br /> �r, b aS,�zj1 Inspection Date 3 ,fh, <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> �M �^- �^ j Q 0 Q PM Z O Q ® PM <br /> l Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O O Inactive ® Truck <br /> Longitude — O Planned ® OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ------------------- <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder O Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <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 m / m / m <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/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 ® In Compliance - No Violations <br /> Q 1 Other: § <br /> Comments --Ty <br /> r /!?� <br /> Inspection Form Included: Q /J C( Cy <br /> Comments Included: Q —l��G�tOC�L1-- -- 0709c 5�5�/L}� am— `LS <br /> B mess Rep's Signature Phone Number I p to s ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect I\� i�/] I 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py: A ■ <br />