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-s� Waste Tire SUOY & Inspection Re <br /> o nspection Report Number <br /> State of California <br /> T 1 <br /> California Int <br /> CIWMB <br /> 181(Neew 04104)Management Board Survey Form - Page 1 i t 1143559 <br /> gratePart A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � ,f•� ( Inspection Type (Fill one) I <br /> Site Suffix: r U ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �(ktki() u,n� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> UA- <br /> � O r s � � 1 � �n�+ Inspected By Inspector <br /> Physical Address 7 e r�a ' i ���`111,...,1 <br /> Inspection Date 3 , <br /> Time In Time Out <br /> Business Rep 1 Title ` o O AM n f 0 AM <br /> �e--rnUlf�(/`C�i �S�iiS� - ltr• !,. I � PM d V ® PM <br /> - - - - - - - - - - Operational Status Tire Type Business RoleStorage Type <br /> (Fill one only (Fill all that apply) (Fill all that appl)) (Fill all that apply) <br /> Tire Count(Whole/PTE) 3 <br /> 0 Active Q Passenger I$ Generator Q Outdoor <br /> Latitude Q Closed Q Altered <br /> CAPS Q Hauler ® Indoor <br /> D Q Inactive 41 Truck Longitude - Q End-Use Q Container <br /> Q Planned OTR <br /> - - - L -L - <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 o Other QStctQQ� s1 lCS <br /> I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 1 ENFORCEMENT STATUS <br /> j V A !HAULING AND MANIFEST REQUIREMENTS <br /> �i 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 <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 ® 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 1@ In Compliance - No Violations <br /> Q Q Other: § <br /> Comments f I <br /> CA <br /> 1 -y l A C,c. LA 9,S Thp. -Qlc win 6�J�s u�e� hc� ave <br /> C.J 1GW to Luo - U_�.1310a► -_4111x0 <br /> l- ) <br /> Inspection Form Included: Q <br /> Comments Included: �r's <br /> Business Rep's Signat Phone Numbers Insure hone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X ,/', N/ ! x L 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C y:LE <br />