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Waste Tire Sui y & Inspection Report nspection Report Number <br /> -liSaT Slate of California <br /> « >< CIWMB181(New04/04) Survey Form - Page 1 I1 - 1141024 <br /> California Integrated Waste Management Board <br /> Part A. _ BLUE_ OR BLACK INK_P_ EN <br /> Business Profile Inspection Details <br /> TPID- 2 _ ® I Inspection Type (Fill one) <br /> Site Suffix: C� O ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: j� �G:fr�a Cc0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J (UJ ✓ Inspected By Inspector <br /> LAS SCA-vWC�_Io <br /> Physical Address <br /> �j . <br /> Inspection Date Q <br /> CA � I <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> U ® PM 0 7 S_ 0 PM <br /> --- Operational Status I 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 /> .2- 6 0 Active ® Passenger 0 Generator 0 Outdoor <br /> Latitude O 0 Closed 0 Altered <br /> GPS 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 40 OTR 0 End-Use • Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - ..._... _ --... _. <br /> V <br /> A 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 Date m / m / m <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 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 A In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> lnl t:tcy�c�c.rl <br /> Inspection Form Included: 0 1 `` <br /> wj <br /> Comments Included: 0 �/ C 1�' S <br /> — Busin a 's Signature Phone Number II1SpeCtor'S Signature Phone Number <br /> —� <br /> INSTRUCTIONS ON BACK Correct:* Incorrect X E__?{ A P LjEj 1 '12 3 62081 3l <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />