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:::�.Jl Waste Tire SuWy & Inspection Repor Inspection Report Number <br /> State California <br /> CIWMBB 181(New 04104) Survey -Form Page 1 1 - 10 7 "1 8 9 <br /> t <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br />{ TPID- _ Inspection Type (Fill one) <br /> Site Suffix: Routine 0 O P O 0 <br /> Re-inspection Referral Observation <br /> Local -�5- If Referral,choose referral type(Fill one) <br /> Identifier: `: it-) 6SS �L,o ; �r,i 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector ? <br /> Physical Address f.' i <br /> t GYl L_I I c <br /> I -`I - (.�)Qhr A,,e I <br /> Street <br /> Inspection Date <br /> I Time In 1 Time Out <br /> City State Zlp Code <br /> Business Rep Title l 0 AM O AM <br /> _ W � m0PM 0 P <br /> C - i mfr Operational Status Tire e 7 Business Role Storage Type <br /> AV <br /> Tire Count (Whole/PTE) r- 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> MO ,0 Closed 0 Altered <br /> Latitude . <br /> GP$ 0 Hauler 0 Indoor <br /> IO 0 Inactive 0 Truck <br /> i <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <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 (2) Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> tiC\1� Y�-"CtNV t4`"yo` r,l('rl <br /> tfp� —_C <br /> (1x \11 i::., c,lf)`j JC'r AC <br /> Inspection Form Included: 0 <br /> Comments Included: 0 --� � - <br /> Business Rep's Signature Phone Numbers Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:b Incorrect: X "v �/ ��('I�,�, t E 62081 <br /> White Copy:CIWMB Yellow Copy.Operdor Pink Copy:LEA <br />