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' InaNection Report Number <br /> Waste Tire Sup vey do Inspection Report. ■ <br /> ism <br /> State California I 1 - 1143512 <br /> CIWMB 181(New 04/04) Survey Form � mage � <br /> California Integrated Waste Management Board <br /> _ _ _ BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection DetailsTPID — <br /> Inspection Type (Fill one) <br /> Site Suffix: ' 3 L1 Lj <br /> 6 l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local // __c % j_, if Referral,choose referral type(Fill one) <br /> Identifier: GiQ� U N)'-\ 4f1"1. 1�—/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( Inspected By Inspector <br /> Physical Address ' /�7� jt✓}'1 . 4_t '11 lai <br /> J ;c: <br /> �"`� �j Inspection Date C T Q <br /> t `-" `� � J Time Out <br /> 1 Time In <br /> Business Rep Title O AM rd O AM <br /> '; 5 O PM C7L • PM <br /> �loctt� ql�,�c� <br /> Operational Status The Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active Q Passenger 0 Generator Q Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive �Truck <br /> Longitude — Q Planned ® OTR 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 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 STATUS <br /> V A 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 / m / m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q 0 14 CCR§18459.1 -The 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 EXT) <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 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 Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> 269 595- —ag-Y6 --Q6? - <br /> Comments Included: - --_—�--- - �— --— <br /> B sines ep's Signature Phone Number I pct r' ignature Phone Number <br /> -' 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � � E X P _ <br /> ® - - - ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:L <br />