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Ins ection Report Number <br /> . Waste Tire S y & Inspection Repor � p p <br /> State of California T 1 1088136 <br /> CIWMB181(New04/04) Survey Form - Page 1 11 <br /> California Integrated Waste Management Board ♦ "�J' ._....._—_ _ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile,6 s+ ' `^f�`� r a. Inspection Details - <br /> 1 TPID- ' I I i ' Inspection Type (Fill one) <br /> Site Suffix 9 Lf ® Routine 0 Re inspection 0 Referral 0 Observation <br /> Local ~�- If Referral,choose referral type(Fill one) <br /> Identifier: f.t(� J U Q u l rl C-Gt <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> .__ vt �_—e Gid _... ---� _ <br /> Physical Address — t �� �Q t <br /> Street - [qL7 I <br /> 9Inspection DateCA r-)2 <br /> t, Time In Time Out <br /> City State Z/f'Code _-_ �.,_. <br /> Business Rep Title O AM Q AM <br /> 0 PM 0 PM <br /> ---- Operational Status Tire Type `i Business Role Storage Type <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> ® Active 0Passenger (a Generator 0 Outdoor <br /> Latitude f 0 Closed 0 Altered <br /> CAPS •1mmJJf 0 Hauler 0 Indoor <br /> F__777 F <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer QAuto 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 o PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> I <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 In Compliance - No Violations <br /> 0 o Other: § -- --- — --II <br /> Comments 1 <br /> �.4it �n <br /> r1 tn�ctl _�erV,,rmect -th1� r�a�� ++ ��N�,t _W � C1 <br /> c�cl\tt �etz� Tore , ndk(Icl -Tire s=pasa� �or wasteI lire Cir-mal u-Oo <br /> c a <br /> +►r25 a'fe r-e r,3yed rabO I efw.e r rcAerdcAr ._y of. A-��fQ_� <br /> t1 u.1 ^.,-A(' lrrn �C 1Y;_ t __� l f1 C-7 ;�ffYl <br /> Inspection Form included: 0 <br /> Comments Included: 0 _- - ^,. ..,r •a . ._ <br /> Business Rep's Signature Phone Number Ira pector s Signature j Phone <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: XG�,. �/1 A', P �E� 2 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />