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Waste Tire&%ey & Inspection Re" Inspection Report Number <br /> t•.; State of California j� <br /> `�� CIWM6181(New04/04) Survey Form - Page 1 - i0l 7 3 <br /> California integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPIDf -- 2 ; cc�� [21 <br /> Inspection Type (Fill one) <br /> Site Suffix: n I�:dI o �7 I & Routine Q Re-inspection Q Referral Q Observation <br /> LocalI If Referral,choose referral type(Fill one) <br /> Identifier: - !t 1'� �"c�aqu art CC)LI TQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address L3� I FkTo CGi S <br /> 1 -2- -7, 1 <br /> Street <br /> Inspection Date O t O <br /> I L_oC�� �A ZIP Code t2C�I Time In TimeOutCity State <br /> Business Rep Title 0 AM O AM <br /> 0 PM Q PM <br /> Operational Status' e Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 8 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> i <br /> Active Q Passenger Q Generator O Outdoor <br /> ow O Q Closed Q Altered <br /> GPS Latitude m . — Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - • I ' Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet C) Government Q Retreader Q Dismantler 0 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 /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 / m / 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 1 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 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 O In Compliance - No Violations <br /> Q Q Other: § <br /> Comments -, <br /> Cl C) -, 1--•_,_7{-_...— ^may-i_�_ - - ��11da1� —�.i).mak. <br /> j,""Ib E ECA 0n <br /> L� �� ave y� ��rntn <br /> v t lip <br /> Inspection Form Included: Q <br /> Comments Includedf <br /> Business Rep's Signature Phone Number Inspectors Signature L" Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: XA MTP l- , 'l 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />