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LLE! Waste Tire 9ftey & inspection Repc f l Inspection Report Number <br /> State of California <br /> CIWMB 181( e ) Survey Form - Page 1 i 5 - 1 0 1 3 1 8 0 <br /> California Integrated WasttManage <br /> Waste Management Board /1 <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � ^ � - D / Inspection Type (Fill one) <br /> Site Suffix: 3 _ * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or—FacilityName <br /> Inspected B <br /> /� ,, P Y Inspector <br /> Physical Address / <br /> 9 1 -'u11607;,1'k-0t1_g <br /> 3S VS <br /> 3 <br /> Inspection Date ® / 7 <br /> J,4�r� Qvod S o <br /> Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> O PM O PM <br /> - - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other P14V <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> f - - - <br /> �F Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 1, <br /> 0 PRC§42953-Contracts with Registered Waste Tire Haulers. f Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date [0771 <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> VVj /°,e C �fa2 93'3 -- C,6_y4r�- `s w, <br /> Inspection Form Included: 0 <br /> Comments Included: 01 � 21 — ^ � � � ` '�'�'"� _T W'0_�3 <br /> QBusmeXs4s.'Rp Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Corr Incorrect h X A; R I L I El 11 2 3 <br /> 62081 <br /> e� <br /> White CopyCIWMB Yellow Copy:Operator Pink Copy:LEA <br />