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0925.9040633 <br /> ene_ <br /> Inspection Report Number <br /> Waste Tire Su ay & Inspection Repor <br /> State,of California CIWMB181(New 04/04). Survey Form - Page 1 I1 - 1086991 <br /> California Integrated Waste Management Board Y g <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- -31 _ r� ! Inspection Type (Fill one) <br /> Site Suffix: I I `-f U (p V QQ Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �(�/� �o CC /(i(�f` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected By Inspector <br /> Fre � <br /> t -S I-r(� <br /> Physical aAddress <br /> Street <br /> ^5�) Inspection Date <br /> Ck�h <br /> I l� O <br /> City State ZIP Code Time In Time Out _ <br /> Business Rep Title I 0 AM � I � Q AM <br /> _D&rcc S-ane- -- - of pC'z_.AW <br /> PM ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 7 . V <br /> ®Active Q Passenger ® Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive ®Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING ANDMANIFEST REQUIREMENTS 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. C-ompliance Deadline <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 -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 EX7) <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 I 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 C-ompliance - No Violations <br /> Q 1 Q Other: § <br /> CommentsI('(__ 1 S Q M*-S <br /> N c kgs Coo Tri re Sv✓iCe Cu�� r0ri40v0j J-191 <br /> dM . CLQ o b-T mavl.�� YprrvI5u; ed Oo ✓iala�Z�S )U L <br /> Inspection Form Included: Q —� <br /> Comments Included: Q - ! Jn 9hJCW <br /> Business Rep's Si nature Phone Number Inspector'sSi nature Phone Number <br /> INSTRUCTIONS ON BACK �T1. 62081 <br /> White Copy: IW Yellow Copy:Operator Pink Copy:LEA <br />