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_rs�a r i;'.:•__;--_::2:-ism.::;_._- -� <br /> & Inspection Repos L Inspection Report NumberState ■ <br /> Waste Tire Su y p 11 - 1140743 <br /> CIWMBf 8li(New Survey Form - Page 1 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A--Survey - ----_- <br /> - - --- - - - <br /> - Inspection Details <br /> Business Profile - <br /> - I Inspection Type (Fill one) <br /> TPID- 1 1 Q - — —- <br /> Site Suffix: ` { v ® Routine Q Re-inspection Q Referral Q Observation <br /> �� <br /> Local If Referral,choose referral type(Fill one) <br /> Local <br /> (��0 �,�)� Cb1Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Identi ---- 1_ <br /> Business or Facility Name Inspected By Inspector <br /> S_ D . 3 q Rern EscoftV <br /> Physical Address <br /> GI Li so V'- _ Co e f �a . G <br /> Inspection Date 1 � � L' � l <br /> LU roe <br /> b "A Time In Time Out <br /> Q AM I O AM <br /> Business Rep Title 1 Q <br /> ` Q QPM QPM <br /> bv,�e - <br /> t Fill all that apply)- <br /> --_--_-- — Operational Status Tire Type Business Role Storage Type <br /> --------- ---- Fill all that apply) (Fill all that apply) <br /> (Fill one only) ( p ( <br /> Tire Count(Whole/PTE) Active Q Passenger Generator t�Outdoor <br /> ----- - - - - --- --- - Q Closed Q Altered <br /> Q Hauler IS Indoor <br /> GPS Latitude O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR <br /> Q End-Use Q Container <br /> Business Type (Fill all that apply) -- <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q <br /> 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 Q Other <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT ST <br /> ATUS <br /> v JHAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> QQ PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q Compliance Deadline <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days ---- <br /> Q Q 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 <br /> Q Referred/CIWMB Enforcement <br /> Q Q -- -- --------.—. — --- <br /> 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 Compliance - No Violations <br /> Q Q Other: § <br /> 1 <br /> Comments n _ iA\nSL �s�Zls� ` 1ef <br /> 1 '� �n� <br /> - <br /> 00 �t - In <br /> Inspection Form Included: QI �C 1 179 <br /> A7 - <br /> Comments Included:• - Ins or's Signature O one Number <br /> usiness ep's Si ature Phone Number -_ P_ _ - - <br /> - 62081 <br /> INSTRUCTIONS ON BACK I Correct:* incorrect: , �/; P k o FA <br /> ` T <br /> .� White Copy:CIWMB Yellow Copy:Operator Pink <br /> ® ■ <br />