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O�ZSQ45Ugbb <br /> eee_ <br /> Waste Tire Moey & Inspection Rep Inspection Report Number <br /> State B 181(New S u rve Form - Pagel I 1 - 10883 0 4 <br /> CIWMB 181(New 04/04) �/ <br /> califomia Integrated Waste Management Board J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 11131 Ol j <br /> L� , Routine Q Re-inspection Q Referral Q Observation <br /> Local �\ 1 If Referral,choose referral type(Fill one) <br /> Identifier: LS(A ( \D n ( (� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business o Facility bWme <br /> 1v^ v" Inspected By Inspector <br /> Asic- Address I ) <br /> ILe <br /> Street40 <br /> Inspection Date 71 <br /> (/ J <br /> City In y State L!P Code _-_ <br /> Business Rep Title �j Time Out <br /> S AM I I ® AM <br /> I ;� S !J o PM I —, Q PM <br /> - ---- — -- --` `--- " —"— -- Operational Status Tire Type Business Role Storage Type <br /> The Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f Q Active ® Passenger ! Generator ® Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude I I Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - i Q End-Use Q Container <br /> 1 Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 4P Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body • Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q 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 /> 01MIM,AULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of diolation 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 /> QQ 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 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 1 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 ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> o _11s I(Aa�rVA 4TV&— - <br /> ow <br /> �V\ A-% <br /> -�i.���-.N�.W'E�.��-W a�W A�4o_�.�- �,�n-Ot�r_a_� _S�c►_�Q�5 S,- <br /> Inspection Form Included: p <br /> Comments Included: ® <br /> Business Rep's ature Phone Number Inspe or s Signature hone Number <br /> INSTRUCTIONS ON BACK 62081 <br /> ExAMP L E 102131 . <br /> White C Yellow Copy:Operator Pink Copy.LEA <br />