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Waste Tire SAy & Inspection Repo rfeInspection Report Number <br /> 7771.. State of California <br /> �fI'1Zl CIWMB181(New 04/04)Management Board Survey Form - Page 1 0 Q o t <br /> 11 <br /> California Integrated Waste Manage <br /> Part A- Survey --- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: \ `a �\ V ` Q Routine o Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: S GI1� o<.4�tt�,t� W u�^^� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> I Inspected By Inspector <br /> L i'.L�. T oz ' S <br /> Physical Address <br /> C, Inspection Date l 7— O -5 <br /> 5� �c,�-�� ��Z�3 <br /> Time In Time Out <br /> Business Rep Title _ O AM O AM <br /> PM Z t7 PM <br /> �Zy-Y\ - <br /> Operational Status Tire Type Business Role Storage Type <br /> (F it one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> f ® Active Q Passenger ® Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 I A HAULING AND MANIFEST REQUIREMENTS <br /> ® Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation ® Extension <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 (a)(b)(c)-Tire Program ID Number from CIW%iB Y <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or t_xr) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years *n+ <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred.,/CIWMB 'Enforcemenx'� <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> CCR 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 3 >� <br /> Q Q 14 § y q Q In Compliance No Violations , <br /> Q Q Other: § P \ I n I ---- — -- ---- --- -- <br /> Comments �. ���.�{{J���� bin,Lll.(�\-{,� l �.�5 (� c��-t t ����`o�• -__ <br /> otic Q(� \Z l7 Dt�;) r �\-I>y lv �il�r%t1ctG l \nit X�(J A Lu.�iuk <br /> ''vth\ <br /> Inspection Form Included: Q <br /> L� <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Ins ctor's Signature Phone Number. <br /> Incorrect 62081 <br /> INSTRUCTIONS ON BACK Correct. X � t XIA N <br /> White Copy:CIWMB Yellow Copy O.._,a:^r Pink Copy:LEA <br />