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08010040140 <br /> eee <br /> Waste Tire Survey $ Inspection Report Inspection Report Number . <br /> LL9s�t°°' "'omW Survey Form Page 1 1 1 - 1 0 7 3 4 8 2 <br /> CIWMB 181(New 04104) <br /> celifomla Integrated Waste Management Board <br /> Part A-Surve BLU_E OR BLACK INK PEN <br /> Business Profile Inspection Details. <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: y 3 y ®Routine . Q.Re-Inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> I Les Sc 6w <br /> Physical Address . 3 9 - / 0 / /-ma-- <br /> Street o h►.—Gra..<�r_L.r, _moi- I _ <br /> Street <br /> Inspection Date <br /> Q <br /> City St to 0 IP God Time In Time Out <br /> Business Rep Title 0 Am 0 AM <br /> m-m®PM m'm ®PM <br /> Operational-Status Tlfe Type Business Role•. Storage Type <br /> Tire Count(Whole/PTE) I r I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Passenger ®Generator Q Outdoor <br /> l ' <br /> CIPS Latitude o Q Closed Q Altered <br /> W-I 1 l <br /> I - I <br /> O Q Inactive 0 Truck ®Hauler ®indoor <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fillall that apply) —-- <br /> ®New Tire Dealer p Auto Repair p Trucking Fleet p Government Q.Retreader Q Dismaritler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q.Crumb Rubber <br /> Q Service Station •Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V MIM2AIDLING AND MANIFEST 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / 111 <br /> / m <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of.Comprehensive Trip.Logs within 90 days (Required for NOV or DCT) <br /> Q 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 /> O Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® Com I ante - No Violations <br /> 01-0 Other: §, <br /> Comments / <br /> -- _ -._._ _C'�L•N2L�p�,� '�v So�t., �StS �i_+���dL__�,1v G�i_��lc, �y <br /> afdI2'L�—/I/o <br /> Inspection Form Included:Q y / <br /> Comments Included: Q _ Ga'�06 Z er <br /> Business'Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct co ect: E X A M P[LIE1 11f2131[LIE <br /> 62061 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br />