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.:.A Waste Tire <br />e & Inspection Repim Inspection Report Number <br />State of California <br />^ 17 <br />CIWMB181(New 04104) Survey Form - Page 1 i 1 9. 10 2 5 c� l21 <br />California Integrated Waste Management Board I - - - - <br />Part A - Survey <br />Business Profile <br />TPID - —� <br />Site Suffix: I I I I W <br />Local <br />Identifier: t <br />Business or Facility Name <br />BLUE OR BLACK INK PEN <br />Inspection Details III <br />Inspection Type (Fill one) <br />0 Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Inspected By <br />Physsl Address <br />LIS G J\1 Jr - <br />et <br />CitV I State ZIP Cod <br />Business Rep Title <br />Tire Count (Whol <br />Inspector <br />G I JP kk r1�► �� t. <br />Inspection Date( -1 / <br />Time In <br />m:C <br />Operational Status <br />(Fill one only) <br />Active <br />0 Closed <br />® Inactive <br />0 Planned <br />O AM <br />O PM <br />Tire Type <br />(Fill all that apply) <br />0 Passenger <br />0 Altered <br />0 Truck <br />0 OTR <br />0 Retreader <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <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 <br />V A HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />n <br />' (-) <br />Other: § . <br />Time Out <br />0 A <br />Illl--- O PM <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />® Generator 0 Outdoor <br />0 Hauler 0 Indoor <br />0 End -Use <br />0 Disi-nantler <br />0 Container <br />0 Tire Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />0 In Compliance - No Violations <br />Comments _/ �. <br />�� <br />F.a !1i ! rt✓i��' (:'f.1l:iCft\^�It'✓ r ! <br />If ID IC �� `;;1r0C1Qd- (I5td tr't 5ot1�fvir <br />IF <br />-� j, <br />vGilff \`- I1(C� I>f`CKl%Gr"� 1t4r%iCt--1;.(i/ C. -(t` 0"d - <br />l.' - <br />spection Form Incl <br />Comments Included: 0-- -- - - - - <br />Business Rep's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: <br />White Copy: CIWMB <br />Incorrect: X %y <br />Yellow Copy Operator <br />Inspector's .Signature <br />I. X,A M1 I L I El I 12 3 <br />Pink Copy: LEA <br />Phone Number <br />62081 <br />