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01354040055 <br /> . t`eea Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California ■ <br /> CIWMB 181(N-0004) Survey Form - Page 1 1 1 - 1 0 7 3 4 9 0 <br /> callfomia Integrated Wall,Management Board - - ....- . -- -3 -4 ----- <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) { <br /> Site Suffix: l , 1 b y _9 _� / f)Routine Q Re-inspection Q Referral p Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ^r c�q��W Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> fw►e r( a.v�.Tiurac_ Trot <br /> Physical Address C� - IF0 / LA.,dl <br /> Inspection Date <br /> GA 5.s-374 - 1 _ - — <br /> 5;ar. %in Time In - Time Out <br /> Business Rep Title - Q AM - -I Q AM <br /> 0 PM I •PM r <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 Q Active Q Passenger Q Generator 0 Outdoor <br /> GPS Latitude <br /> D Q Closed Q Altered <br /> 0 Hauler Q Indoor <br /> D .Inactive 0Truck <br /> Longitude - 0 Planned 0 OTR O End-Use Q Container <br /> Business Type.(Fill all that apply) <br /> O New Tire Dealer 0 Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> O Service Station 0 Hauler 0 Agriculture Q Shredder ®Other —1 fuek <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A j HAULING AND MANIFEST REQUIREMENTS <br /> O O Q Notice Of Violation Q Extension <br /> 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> O Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance'- No Violations <br /> 0 Q Other: § <br /> Comments <br /> _ �"YKm±—t►4S�Q�L�+" 61'�Tk-�� D-V-O ^ktXLf ��ee,w <br /> -►� 'ub�d ar -,J- j�y�p <br /> Inspection Form Included:O ;� '� r �1 Q 4-4,h �p it/ ✓ <br /> Comments Included:Q 'e hob$—D 6 tj <br /> Business Rep's Signature Phone Number Inspector's Sig ature Phone Number <br /> 62081 <br /> ■ INSTRUCTIONS ON BACK Correct:* Incorrect:VX( V 11E�XJAMJPILIEI1 2 3 ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />