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Waste Tire S,... .ey & Inspection Repo* Inspection Report Number ■ <br /> State of California Form - P a e 1 I 1 - 1143467 <br /> CIWMB 181(New 04104) Survey g <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> PartA- Survey -- - - - <br /> -- - - — - <br /> Business Profile Inspection Details <br /> TPID- l Inspection Type (Fill one) <br /> Site Suffix: L� l t) Routine Q Re-inspection Q Referral O Observation <br /> Local ``^ If Referral,choose referral type(Fill one) <br /> Identifier: �_�C�� � 4 J�A 66L/A( O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Add . c} �YAbv <br /> aa� S . U\tyv h Ie(f_, Lr, <br /> ,ry� Inspection Date -7l 5 1 <br /> L t Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> /-� <br /> �PM ' C� PM <br /> - — — - - Operational Status I Tire Type Business Role Storage Type <br /> ` <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> O Active ®Passenger ®Generator Q Outdoor <br /> D 0 Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> D 0 Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O 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 O 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 /> 0 Notice Of Violation Q Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q j O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance - No Violations <br /> O 0 1 Other: § ��, <br /> Comments ,/� !,l <br /> - 6_ju_�_ � A6 V;D c';h 20s Or 6!- <br /> -Acepift m vt /cam .1� ' 141 a1 _ <br /> Inspection Form Included: 01 G�� <br /> Comments Included: 01 —�.- - -- --. ----�4�rte DO-`26-) <br /> Business Rep's Signature Phone Number s e S nature Phone Number_ <br /> INSTRUCTIONS ON BACK ' Correct:* Incorrect: X A I L7 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:L ® ■ <br />