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■ '; Waste The SIA. & Inspection Repor #_ <br /> spection Report Number <br /> ' State of California <br /> CIWMB 181(New 04104) `.: Survey Form - Page 1 Il 1088234 <br /> California Integrated Waste Management Board g <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Busrri�ss ProfileaInspect�o(7 Details - <br /> _.__.._ <br /> Inspection Type (Fill one) <br /> Ste Suffix: 1 1 -512-10 3 3 �� Q Routine Q Re-inspection Q Referral ® Observation <br /> 9 _ <br /> Local -, � If Referral,choose referral type(Fill one) <br /> '- +T <br /> Identifier: _ � �-S^O Q 1.t i n C_O 1.1(1 <br /> �.�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> _ Inspected By Inspector <br /> Business or Facility Name <br /> Physical Address _ 9 <br /> J _� ��_�._�.._-�! r►_`: 1 of LsCct� __d <br /> Street <br /> Inspection Date <br /> L S+A CA-*�r, �� S Z 15 1 <br /> J� �( <br /> _ _._.__-_.,..-_.. Time In Time Out <br /> City State ZIP Code T- -._..__ <br /> Q AM <br /> Business Rep Title 0 AM <br /> �Y 0PM � 0P <br /> 9 o Operational Status Tire Type Business Role Storage Type <br /> 7� 77 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �" ; ; ® Active Q Passenger Q Generator Q Outdoor <br /> l � C Q Closed Q Altered <br /> Latitude <br /> GPS � Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Q Planned Q OTR Q End-Use inerLongitude <br /> Business Type (Fill all that <br /> Q New Tire Dealer Q Auto Repair Q 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 ® Other c} <br /> Part B - Inspection of Waste Tire Dealer, Generator Hauler and End-Use FacilityENFORCEMENT STATUS <br /> p_ _ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> PRC 42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q ! § 9 P <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance Deadline <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 <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 <br /> (0 <br /> , II In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> n+� tc.t1 +n _ on--� ' r vrrr _ 'E�I_ CSnI� ThC T6� �ck .t_ ril cI Wra= <br /> -VNres Si% rcd �t� 2 • F4_ + t� +_ c� how—�1-D�-tt��_ kf)erc��Jor. La-Z <br /> c ' 9 <br /> '1 W11-sq n lr,)�y Cir'e C m at„ � <br /> _. Y CAI <br /> _ - 'v1 <br /> Inspection Form Included: 0 <br /> Comments Included: Q�B�isinessRep's Signature Phone -- pest i lr� <br /> i 7 -- ors Signature 'hone Number <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: ,� ,�,�, P i L � ���� 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />