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ya1 uaraci <br /> _._ Waste Tire SApey � �n inspection Report Number <br /> Inspection Report <br /> State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 �+ 1 Q 2 z 3 <br /> California Integrated Waste Management Board <br /> Part A- Survey _ BLUE BLACKINK BLACINK PEN <br /> Business Profile inspection Details <br /> TPID- I ' Inspection Type (Fill one) <br /> Site Suffix: 3 3 `T(f; C � ® Routine 0 Re-inspection Q Referral Q Observation <br /> Local ''j' I If Referral,choose referral type(Fill one) <br /> Identifier: 1! Caf/L TJ L,ns�ti.L/I CriLLFkL Q CHP Q CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name F - - - - - - <br /> Inspected By Inspector <br /> Ir �r L'Ioes LCC <br /> Physical dcress i - / C J \:je,uA_L Z <br /> Lv Ce ��2 Inspection Date C / 1 C <br /> T ' S <br /> Time In Time Out <br /> Business Rep Title rl Q AM O AM <br /> ® PM D ® PM <br /> - - -- -- - --- - <br /> Operational Status Tire Type Business Role Storage Type <br /> CI (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> i ® Active O Passenger ®Generator 0 Outdoor <br /> Latitude 0 1 O Closed O Altered <br /> GPS ue D Q Hauler Q Indoor <br /> Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair (a Trucking Fleet O Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer O Collection O 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 /> > -- -- - - i <br /> V ! A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension j <br /> O O 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 m / m / F11 <br /> O Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> (Required for NOV or EXT) <br /> O Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforcement <br /> Q 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 ® 16 Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> _` t�S c� Lti,tz rt��'e��� <br /> Fztc�l� r uses rei} e- -- I-0- o <br /> J - <br /> d cv sty +F� es__ Ca <br /> _�kbeA fire_ ttias Fe_ -Kr-e-S 6 q st`+e , <br /> No ✓_I <br /> - <br /> Inspection Form Included: Q , <br /> Z)��U L/ p <br /> Comments Include - - �� L i L <br /> uslness ep s Signa ure Phone Number Insp tors i nature hone Number <br /> - - - - - - <br /> INSTRUCTIONS ON BACK ' Correct: Incorrect: ( 62081 <br /> � X�a hM1 PIL �': 1 ; 2 <br /> White Copy:CIWMB Yellow Copy:Operator P-<Copy:LEA <br />