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EHE. <br /> Waste Tire Su .1y & Inspection Repor*Inspection Report Number <br /> State IIHi- CIWM f 81(Nrnia Survey Form - Page 1 1 7 - 1 0 7 9 1 9 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile !Inspection Details <br /> TPID- p Inspection Type (Fill one) <br /> Site Suffix: ( ® 8 3 0 40 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> L <br /> Identifier: Sar) TDag .X'%n Cout1t� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ,Mo,ote-ca AL-fo P1ozcA _ <br /> Physical Ad ress 3 9 o ,/ <br /> hT 1S'}l QYl LtAGQS <br /> 1 ICl0 5 • M 0. In SA. <br /> Inspection Date U 3 / 2 �O o Q <br /> i`�Grl�eca G X15337 <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> F1XPC� Q PM O PM <br /> 1`411 ke Pcatfo n c rccr%Ori p,c-. - - - <br /> ---- --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> C) 5 <br /> • Active 0 Passenger •Generator ! Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <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 40 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 HAULING AND MANIFEST REQUIREMENTS <br /> I Q Notice Of.Violation Q Extension <br /> O 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance,Deadline <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> ---- --- --- --- - - <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers j Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 , In Compliance <br /> Q Q Other: § <br /> Comments <br /> .N-TM o b r - <br /> Iasi- 2 yrs. `Tis ct (o�j- vn��+ _ neirr OL -- 'le_6c e-s- - <br /> L v1o`ctik r aS Lifl \ <br /> Inspection Form Included: Q' �// i (, { _ (zoq) <br /> Comments Included: Q 1/ " �6 l�Z•`�� 901111 68 j(78 <br /> Business Rep's Signature Phone Number Ins or's Signature Phone Number <br /> INSTRUCTIONS ON BACKg�gr {J A p1'1[2131s2os1 <br /> y <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />