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6���64404�4 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> LEState of California <br /> i CIWMB181(New 04/04) Survey Form.- Page 1 FI1 1108469 <br /> California Integrated Waste Management Board <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) i <br /> Site Suffix: 1 161 Q 15-T51 ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier. <br /> �+�`�_ 0 N" l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — -- <br /> �{ \,� Inspected By Inspector <br /> Physical A4dress q L n�ScLkgI�l_l.t <br /> I 2 _ f 'n <br /> L7_ <br /> Street f}� J�ornb�Ic�J <br /> Inspection Date <br /> &CY) <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title ^ I AM 5 1 r Q AM <br /> 0 PM <br /> 0 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 /> t ® Active ®Passenger ®Generator ® Outdoor <br /> Latitude 9 D Q Closed Q Altered <br /> GPS I Q Hauler Q Indoor <br /> ---' . Q Inactive ®Truck <br /> Q Planned Longitude - I OTR <br /> Q End-Use Q Container <br /> ® <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 0 Other LLLL.n LOI)) — <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 1111ENEOR01EMENT_STATUS <br /> M1 q HAULING AND MANIFEST 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. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> QQ 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 FXT) <br /> Q iQ 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/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 /> 1010 1 Other: § LI _ <br /> Comments �QU1l 12> cryo—_--kid_l_S_�GL 7z (AYl <br /> Ab) a✓1 b <br /> Inspection Form �nc <br /> ncluded: Q <br /> Comments luded: Q �b%� <br /> Business p's Si ture Phone Number In p ct is S' nature Phone Number <br /> INSTRUCTIONS ON BACK Co7ectj=c6rre:ct=- FETxrAjMjP[Lj <br /> s2os1 <br /> White CopYellow Copy:Operator Pink Copy:LFA <br /> i <br />