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Waste Tire Sy & Inspection R-epol -InspectionReportNumber <br /> California7,IIS State of California <br /> .e <br /> CIWMB181(New04/04) SUrVe Form - Pa e 1 1 10 7 3 4 5 5 <br /> Integrated Waste Management Board Y g7 - L ------ -- ---- — <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` �Q .�� O ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: `��� 7OCI�Ld rl �Ol.l(1 1 t� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 1 01 1 V1 ; � ,C; L. i :j <br /> Street <br /> Inspection Date 5 O 1 O Q <br /> l <br /> H'CA Cc.Q C.A 1 v <br /> City State ZIP Code Tri"me In Time Out <br /> Business Rep Title _ L I I 0 AM 0 Am <br /> O PM , m 0 PM <br /> �t N(.2ChQ�11 C. J <br /> Operational <br /> Status: Tire Type apply): (Fill Buallsiness <br /> Rol apply) (Fill all Ty(Fill oneapply) <br /> 0-ire Count(Whole/PTE) ` <br /> ®Active Passenger ® Generator Q Outdoor <br /> ( <br /> GPS Latitude D Q Closed Q Altered <br /> .L Q <br /> J�f Hauler O Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> ALI <br /> Business Type (Fill all that apply 1119iiiie <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q 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 ® Other t���(okcAor �[Qhl�\ Ir�- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O 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 /> O 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 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 /> 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments Too 1,06 <br /> [ ll 0 (f"j y: <br /> —)C-AS err cue �—CL� �,���� 1 i—Q1 dot ) V01; wo rc n or # or it CS�W I C <br /> ter : Ml ' S 1� <br /> Inspection Form Included: Q <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Inspector s Sig Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X �, C X I A ,Wt P E, 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />