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-_I..-• -_--.a-__-nLl� JY_ .rp,1�F.-+F.:.. .CTRL-. 'WSF-.P�8�4 _.-.. -..-. ......- 1.� .- -1. _..W_, .JL - ,.�_-. <br />Waste Tire <br />Su Inspection Report ctionReportNumber <br />---- State of California <br />-r--- CIWMB 181 (New 04!04) <br />form- <br />California Integrated Waste <br />SurveyForm-Page1 <br />1 5-1 <br />025677 <br />Management Board <br />Part A - Survey <br />BLUE OR BLACK INK PEN <br />siness Profile <br />Inspection Details <br />TPID - <br />Site Suffix: <br />1 <br />1T3TG <br />-I <br />- �/ <br />Inspection Type (Fill one) <br />I <br />kr Routine Q Re -inspection Q Referral on <br />Q Obsery ti <br />Local <br />If Referral, choose referral type (Fill one) <br />Identifier: <br />h <br />joa . <br />&kyd- <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name nn <br />i Slt7C k to o A o b <br />,b I SyY .q,,j 1 e K S <br />Inspected By Inspector <br />I -- - <br />U I JPYIYi.L RN,(L <br />I � � f - F/ <br />Physical Address <br />— <br />Street <br />�S�VWI <br />Inspection Date �/ S <br />cit! y <br />Business <br />State Z!P Code <br />Title <br />Time Time Out <br />_ <br />AM Q AM <br />'Rep J� <br />JQVItq ?' - <br />)O <br />tl 01A'v��dpre<�, <br />- 0PM — - QPM <br />Operational Status Tire Type Business Role Storage Type <br />Tire Count (Whole/PTE) <br />5 O <br />(Fill,one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />Active Q Passenger. (0 Generator Q Outdoor <br />GPS Latitude <br />11 � <br />- <br />O <br />Q Closed Q Altered <br />Q Hauler Q Indoor <br />0 Inactive n Truck <br />Q End -Use Q Container <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q Shredder Q Other <br />Q Service Station Q Hauler Q Agriculture <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V I A HAULING AND MANIFEST REQUIREMENTS <br />Q Q PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q Q PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q Q PRC § 42956 - Registration/Decal in Vehicle <br />Q Q 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q Q 14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q Q 14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q Q 14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />Q Q 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <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 <br />Q Q Other: § <br />Q Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date <br />m/m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />O In Compliance - No Violations <br />Comments q C 0 t 1, 7–P i'1P0lP1 I— ' /L4Ct nd will <br />%s rPajsfiere%rC, Jtdee- -for-011 rkt ulos-f � t�`re �ra�1� al a <br />yywni�gL Ct�Q.i+Gt�1�¢' � �t f (Vb��. R� fiC�in, WnS�� c/ C1�'ijr�T <br />all <br />Inspection Form Included: Q <br />Comments Included: Q <br />Business Rep's Signature Phone Number In*pector's4Si9,naxure - �, Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: X /j- � i7XTAMjPjLjEj It 2 3 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />