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,:� ::. t. w -n�-.--._--L..y-1l�qn�.,.+v.. .._-RS•A-.�.ae�•.-. _ ."AiL .-Flo.+,-e. <br /> I — <br /> f <br /> --A Waste Tire 'my & Inspection Rep _inspection Report Number <br /> kaState CIWIVI 181(New Survey Form - Page 1 1 8 - 1 0 0 8 7 7 0 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Managergent Board -_----_ ....__._ _....... __........ <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> 5171- - <br /> IN <br /> 1171"11-91 F <br /> �. <br />+ TPID- � - Inspection Type (Fill one) <br /> Site Suffix: 1 1 / 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ( // ) If Referral,choose referral type(Fill one) <br /> Identifier: ` a-� v{ (,'l v t �;G•i ,,` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> - -- <br /> Business or Facility Name Inspected By Inspector <br /> La f lv 1, <br /> Physical Address — <br /> i <br /> J01f � ._ v��dl,c �,•c� t� I <br /> Street <br /> ) Inspection Date <br /> City r Slate ZIP Code Time In Time Out <br /> Business Rep Title , C)AM t l" O AM <br /> p 1 f 0 PM / 0 PM <br /> Operational Status 'Tire Type Business Role Storage Type <br /> 1." (Fill one only) (Fill all that app (Fill all that apply) (Fill all that apply) <br /> T re Count(Whole/, re, r' / t 1 <br /> Active Q Passenger Q Generator Q Outdoor <br /> ( � 0 Q Closed Q Altered <br /> GPS Latitude W . Q Hauler Qlndoor <br /> D Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> 40.19MIS Type {Fill all tha;a�o)Y)� <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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A rHAULING AND MANIF=EST 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 <br /> M / M / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 Q In Compliance - No Violations <br /> Q Q Other: § - - <br /> Comments f 1 `( <br /> t; U Cit I''' �ti1 tJ f�G1tit h .{ (k [ 1U�/UyoI+,1 b`:J(t'. ✓d ' ,1/)� t �l e <br /> � yv <br /> -tic) ctb"M ai dif(crevJ JuccdtLn : On FIvry <br /> jn <br /> ✓ �C' t. ��✓." at ( � �? r� � FQ •trLACly <br /> Inspection <br /> Comments Included. ( : : :, „. _ <br /> Business Rep's Signature Phone Number ector sS�tgnature Phone Numb <br /> J - --�_ <br /> INSTRUCTIONS ON BACK Correct: Incorrect. ', �/ A p 1 a 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> I z. <br />