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U:3LIU iAUgIs <br /> Waste Tire SuOey & Inspection Repo Inspection Report Number <br /> k11111ilm <br /> State ot.CaliforniaI 1 1 0 8 6 9 2 6iiiii <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> Califomia Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local I v` r t / If Referral,choose referral type(Fill one) <br /> Identifier: nJ ,(�(� l� f-7 / Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — �')) `7 <br /> Inspected By Inspector <br /> L-G_r_le c�llei-T_runs f —� ]__� <br /> _ 1 D <br /> Physical Addredressss <br /> Street LLc( <br /> J <br /> L�aL� q � Inspection Date ,�J <br /> City State ZIP cc _n Time In _ Time Out <br /> Business Rep Title ® AM AM <br /> L/ —� O PM i - J O PM <br /> IL&ob6D__ <br /> t. — Operational Status Tire 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) a !o. <br /> ® Active Q Passenger 0 Generator ® Outdoor <br /> 10 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> -.O Q Inactive ® Truck <br /> Longitude _ . I Q End-Use Q Container <br /> j Planned O OTR <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 I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 01MIHAULING 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 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 EXE <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 OLl d0--ne cw 16 —C <br /> _ /e <br /> AQc�� c� c�_c�s �oc� <br /> A Czlb(Q—,�7Y) cam- _� o i� - <br /> Inspection Form Included: Q <br /> Comments Included: Q y <br /> Business Rep' n tures Phone Number Ins4c r's` "g ure Phone Number <br /> INSTRUCTIONS ON BACK •orre t: fneorrect: X JUl P L E 1 :2 3 62081 <br /> 'White C py:C M Yellow Copy:Operator Pink Copy:LEA <br />