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Waste Tire Su y & Inspection Repor ' Inspection Report Number ■ <br /> State of California 11 — 1088015 <br /> CIWMB 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 - <br /> TPID- ( r , Q Inspection Type (Fill one) <br /> Site Suffix. �Q ii Routine Re-inspection Referral Observation <br /> Q p Q Q <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Ari �UGu n C UUYt�-U <br /> J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Id.e. Gol� Coun+Y G1u � <br /> � <br /> Physical Address___.__._._—.,-------_s--- <br /> LL ►' 1 I a �C9 <br /> O <br /> Street q <br /> -- Inspection Date <br /> CA G 5 21 Vii' , "Z q IIIvv EIEC <br /> State Z/P CodeTime In Time Out <br /> Business Rep Title 0 AM AM <br /> O PM 0 PM <br /> ,_L_Q u S► V C= f a_— — --..._ I S u er ti c�te��cent", J­�] _._. .. . <br /> Operational Status Tire Type Business Role Storage Type <br /> e (Fill one only) (Fill all that apply)i (Fill all that apply) (Fill all that apply)' <br /> 1 )� ® Active Q Passenger ® Generator Q Outdoor <br /> Q Inactive Q Truck <br /> Q Hauler Q IndoorGPS Latitude Q Closed Q Altered <br /> Q+0 Q End Use Q ContainerLongitude Planned Q OTR <br /> -- - - <br /> Business Type (Pill all that apply <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q 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 ® Other GA Cdul(S <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility [ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline " <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q _. <br /> Q ' 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 40 In Compliance - No Violations <br /> Q Q Other: § <br /> a�.c.. I C n - �Q+L dry <br /> Comments go <br /> 1� <br /> s� <br /> F$_oX.__ 143 wu��CeN�,ed -�-�� s s�arec� cin-st-�"e, �c 1t� _ uses 5 <br /> E, �.r— ,?r li:;'� yr L0a>1Fe Ik5e metre �er,� ) ��' �p �-OQC�623 - 5 - <br /> 4RO1' <br /> r noir a n <br /> Inspection Form included 0 ✓" <br /> Comments Included: Q L <br /> Business Re'p's Signature Phone Number i tors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: >< f <br /> 62081 <br /> �f .art <br /> SWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />