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Waste Tire SLO., ey & Inspection Repo* Inspection Report Number ■ <br /> •`mym,, . State of California <br /> CIWMB181(New 04104) Survey Form - Page 1 I1 1088214 <br /> California Integrated Waste Management Board ! J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site SuffixT ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S on To OlUI✓I Co n <br /> q � j Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> e m 1 0�e,r ct <br /> C1 rk1►�� ,- <br /> Physical Address 3 9 sJt on LU.c.-i <br /> L__1_z6 a V,-J)n r'b l 1+ G <br /> ,Street <br /> -G <br /> Inspection Date , 0 8 O a <br /> L'.0 -,—.____._ C � —�'�3��--1 Time In ` Time Out <br /> Business <br /> _ ----_._---,...,_,.. State IP Code _� _ . <br /> 0 AM <br /> AM <br /> Business Rep Title PM -`_ -� O PM <br /> _1n._ -__,,_Pais M <br /> 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 /> I � ' —1a <br /> Active Q Passenger Q Generator Q Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS - Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply ' "' <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 0 Other ForV'I i -F_ Sn k� Qf/ l_�l�l r <br /> VC . �s i <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 <br /> Q Q 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements Date m M / FT] <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 ® In Compliance No Violations <br /> Q Q Other: § _ I i --- <br /> Comments ( <br /> �Q(t►r& \ fit_ rja-FE +kC �U`JO,J Ior( u)(a.S no*e <br /> ca ,1�t ���es l,U►� ��n Wc-w `T re Co.-Aar tuasllre-_ +ire__ Y2m-�YGM <br /> _ 1r` ey\j ce . Wc,,:A-e -tire_ ure rernaVe() G +ImeS pkv u-egy <br /> -DT-- an 1�Z,-JS VING V ICAQA-lOfL �jY Gf ��` Q U t1 Ce r Y� <br /> " <br /> i m, r4 r y , ""-• �r `" "," �"". 4 h " " iii` <br /> 1 We <br /> Inspection Form"Include <br /> d �� <br /> Comments Included. Q - <br /> BtasineRep's Si nature Phone Number In actor s,,5ignatur Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �/ - ,'.+ L 1, 1 3 62081 <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />