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Waste Tire SA1ey & Inspection Reporo Inspection Report Number <br /> 111 w' State of California I 1 - 1088281 <br /> 1.�� ° SurveyForm - Page 1 <br /> � CIWMB 181(New 04/04) � , <br /> California Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> BusinessProfile Inspection Qetails <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> o alfier: <br /> Id nti � If Referral,choose referral type(Fill one) <br /> far, 7c�nc�iftn C,uu ..1 <br /> J� O CHP O CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Kr-1_'.1 on <br /> Stile& <br /> Inspection Date '/ $ / M�� / <br /> s C A 9 r G 3 Z� _j _—_ <br /> tete ZIP Code Time In Time Out <br /> Business Rep Title ` l 9 O PM O AM <br /> L.._..-1._...--- • �– .__ O PM <br /> onal <br /> usiness Role <br /> TireCount Whole/PTE - <br /> (Fill only) (Fill <br /> Tire <br /> TYpat app (Fill all that apply) (Fill all that apply) <br /> -' Active Q Passenger (M Generator 0 Outdoor <br /> yO Q Closed O Altered <br /> GPS Latitude 9 Q Hauler O Indoor <br /> 9 _ O <br /> Lon O Plantned ive O OTR k Q End-Use Container <br /> Longitude O O <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet O Government O Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B- <br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facilit ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / 7 <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred i CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators in Compliance - No Violations <br /> 0 0 Other: § -- - - _ -_ -- --- --_— - - ---: -- <br /> Comments 4601`Ci: 1r ,Vi UJ�S <br /> �c ecl_• Fc�c,l►-4, t �-e _Mc-Co�_i �"rt�ck : Tir -Se fA cQ- or reirc.-id r�(( � <br /> Wc -'r it r, :,y (Al E137 rrctn�$e `,I�Cc JefP <br /> �Q'r !� P A)1N L1 �n CA :�• l it f-b'f` �� 1')Y r <br /> e I` v 1. _►o tZ._ o <br /> Inspection Form lncluded: o �" .y.� t <br /> r <br /> Z—F W� <br /> ,. r °t ✓ 1 i <br /> Comments Included: 0Business Reps Signature Phone Number Insp ctor s Signature - Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ; 1 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />