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032a70410M <br /> = r18� Waste Tire Su ey & Inspection Repor Inspection Report Number <br /> CrWMState of 181(New <br /> Surveyform - Page 1 11 4 - 10 7 9 3 8 3 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board - BLUE OR BLACK INK PEN <br /> ry <br /> Part A- suey <br /> Business Profile inspection Details <br /> TPID- inspection� � � G o Inspection Type .(Fill one) <br /> Site Suffix: / 1 ,9 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sGyK �a ,r� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> L—C/� ' � I L� X.4A 'r�4 <br /> —] <br /> Physical Address / / ® / s�l,B jpi/1�/"C�✓sQ <br /> /a2 <br /> Street <br /> --(;4� � I Inspection Date D Q 9 Q 9 <br /> City State ZIP Code Time In Time Out <br /> Business Rep 0 AM 0 AM <br /> __ ss__,w, Title lz�] <br /> ; 0 PM P21 0 PM <br /> J Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ! <br /> C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active 0 Passenger. • Generator ® Outdoor <br /> I l I0 Closed 0 Altered <br /> GPS L J Latitude 1 0 I <br /> . L.— l� 0 Inactive. 0 Truck 0 Hauler 0 Indoor <br /> O <br /> Longitude - l—� I. � 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 ® Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V AI HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered.Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 - Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 In C-ompliance - No Violations <br /> 0 1 0 Other: § <br /> Comments ke /��^� �ora/,/ ."'J Gerdy Q�r.� c ��✓>�/Gy`� `"���" <br /> �a2,",ei'��1. �! Ll/i;,�if-a•-r !�(/� �G/'�-y bCo G�tc�B-.i'e �Ci�-� V� /'� . �'�/� <br /> 2�9 <br /> Inspection Form included: 0 <br /> Comments Included: 0 ymer <br /> BusinessRep's Signature . Phone N Inspector's Signature Phone Number <br /> —os 62081 <br /> INSTRUCTIONS ON BACK C rre t: Incorrect: �l I EJXJAI AAP L E 11 [.2 3 <br /> White Co y:CI B Yellow Copy:Operator Pink Copy:LEA <br />