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rte' / <br /> , Waste Tirey & Inspection Repo Aspection Report Number <br /> State of Caldornia <br /> COMB181(New04104) Survey-.Form - :Page 1 I $ - <br /> California Integrated Waste Management Board - <br /> Part A- S u rvev BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ! (� 7 ( Routine (6 Re-inspection Q Referral Q Observation <br /> ocl ar— --- -- ---- --- — - Tf eR fe�rarchoose referral type(Fig`one — - <br /> Identifier: i M <br /> c L t. _ 1, (: +-b ti, 4. Q CHP Q CIWMB Q Complaint. •Q Educational Visit Q Other <br /> Business or Facility Name r Inspected By inspector <br /> I r t�t 17 Yi "117 r\ ^i !3 'p rl. �J'in C k�>t,r!.<? I <br /> Physical Address <br /> ip-.12 i=ce t lr i= I <br /> Street <br /> Inspection Date . / (, <br /> 5 5 <br /> City State ZIP Code Time In Time Out <br /> Business Rep.. Title O AM O AM <br /> ' m0PM ' CD 0P <br /> Operational Status fr`e Type ` " Business Role torage'Ty <br /> tre Count( ole/PTE)" } (Fill one only) 1;all that apply. (Fill all that apply) (Fill all that a <br /> - „- ® Active. 'assenyc.Ir Generator Ortdoor, <br /> Latitude Q Closed (�Altered <br /> GPS L I I Q Hauler Indoo <br /> Q Inactive (-Truck <br /> Longitude - - Q Planned (� OTR O End-Use ,0 Contain <br /> Business Type_ (Fi al that aPPIy) <br /> Q New Tire Dealer Q Auto Repair ( .Trucking Fleet Q Government Q Retreader. _ O Dismantler Q Tire DerivedFuel <br /> 0.-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 /> V A <br /> O 'HAULING AMB ergieRE MEN sO § -WTire Hauler RegistrationTransport of Tires 1 O Notice Of Violation Extension <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 O <br /> 14 CCR§18459.2.1-Submittal of Comprehensive.Trip Logs within 90 days (Required for NOV or EXT) <br /> O 14 CCR§18460.2'-Manifest System <br /> Trip Logs for 3 years i <br /> 14 CCR&18459 3-Retention of Comprehensive <br /> O O m Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§15461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§ -Manifest System Requirements or re Dealers or ase Te Generators <br /> O 18462 MifSRitfTiDlWtirGt <br /> In Compliance - No Violations <br /> O O Other: §. <br /> Comments <br /> POW 11 1 toul Ai 114 dJe ;..� �� l l� .i. ��r,�;�� Ilk 0� <br /> /1C1, <br /> f <br /> OttlNume <br /> Inspection Form Included ® 1. <br /> Comments Included: OrfBusiess Rep's.Signature Phone Number Inspector s Sgnature Phon� 62081INSTRUCTIONS ON BACK '.Correct:� Incorrect: X IExMAMP ;L� 111213 <br /> White Copy:CWMD Yellow Copy:Operator Pink Copy;CEA <br />