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Waste Tire S & Inspection Re oro Inspection Report Number <br /> MRS= <br /> Y p p State of California I .L - 1088020 <br /> CIWMB 181(New Survey Form - Page 1 <br /> California Integrated Waste Management Board ... _ <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business; Inspection Details:::, ;I — <br /> i TPID- Inspection Type (Fill one) <br /> Site Suffix: -inspection t q tt <br /> [PI0 Routine Q Re-inspection Q Referral Q Observation <br /> I - <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: `-`JCA n �UG1G'U i r? ��Uh�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> LS09CalI - L�__ r__ r 5ticar, LoC9sPhysiAddress <br /> st <br /> Street . p 7� / 1 / ®_ Ins ection DateF071 <br /> a Sty to 2If'C _ <br /> M Ckn�ec ! _._-._ 336 Time In Time Out <br /> _. <br /> Business Rep Title ` O AM Q AM <br /> _ I__� �. O PM _ ._-... ....-�- O PM <br /> -_, , , <br /> Operational Status Tire Type Business s Role Storage Type <br /> Q (Fill one only) (Fill all that apply)'] (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger Generator Q Outdoor <br /> O <br /> Latitude ��LL1.___1 <br /> losed Q AlteredGPSQ Hauler Q Indoor <br /> �o Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 9 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 Q 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 /> 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 M / M / EE] <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 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 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> 11�5412�C.�� 101'1 ¢2YO�t�t Ert{.`+ �IcA�2 tOl�avt3�rO� (1 E;�; <br /> -R �roX. -70 _Ljas�e. -hyes._ shored I n 2tS �4._c_.ontc iur on--sl 1-e . FQr X1 7 uses <br /> Gc>ldert- Qv- t�roc�uc � -6r wca5{-z_ ivre remov(ol EPT rnoh&A5 -�/ievied <br /> v <br /> t �>� p� <br /> Inspection Form Included: Q � �� <br /> Comments_Included: Q 1 ... . d "u. ,q6 <br /> Business Rep's Signature Phone Number In bctor"s Signatures Phone I1 i"., e <br /> -- _ __ <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X �,. ' ,3` <br /> 62081 <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />