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�._. Waste Tire y � Inspection Rep Inspection Report t Number <br /> State of California <br /> CIWMB 181(New04/04) Survey Form - Page 1 I �. - 1127590 <br /> California 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 0 Re-inspection 0 Referral 0 Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: v�ti� l, .l � l UL� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector i <br /> - llfl�,10 <br /> Physical Address <br /> A) LI <br /> —,� I' <br /> - I <br /> Street <br /> Inspection Date ......... <br /> I %1 <br /> `J I <br /> .._ \ <br /> LAQ—____ __� � ) t._...__ .. <br /> tWe ZIP C-de Time In Time Out <br /> Business Rep Title _ / 0 AM _ <br /> ` 0 AM <br /> 1 , <br /> Nl <br /> 0 'M (V 0 PM <br /> f__, �l CA�' 1 ..... alit �J ..1._ .. _.. 11....+. xi.. ....y.._.. Gt _-.(!J....-_.I <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire (WholefPTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed <br /> d 0 Ait <br /> oseel ed <br /> Latitude .� � 0 <br /> Hauler Indoor <br /> ==t:- 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> 1 <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 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> I i <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 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> I, L <br /> 1_: 'tti i14 b,_,-V fi(�. - - -- <br /> Inspection worm Included: 0 <br /> Comments Included. 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phov�e (lumber <br /> 062081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 11 °a/ kth, -°A � _L i I L 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />