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;'■ -'- Inspection Re_ <br /> ort NumberWaste fire Suy & Inspection Repor <br /> State <br /> of California j �' (, <br /> sam3 i CIWMB 181(New 04104) SurveyForm - Pa 5 <br /> California Integrated Waste Management Board �e 1 5 - 1 D 1 G 6 9-- - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> 17, 75 <br /> x <br /> Business Profile Ms <br /> TPID- v Inspection Type (Fill one) <br /> Site Suffix: ;� �' ' Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 7 f - f If Referral,choose referral type(Fill one) <br /> Identifier: t611t t !tY ; r• ( 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> -... <br /> Business or Facility Name f { Inspected By Inspector <br /> Physical Address _i ` L. ' { t. Y'[ I'•. t ^✓i ,�.._ <br /> StreetIle p I bN <br /> (\j Ins ection Date I t_ r <br /> city State ZIP Code Time In Time Out <br /> Business Rep Title (( l AM O AM <br /> ' PM <br /> PM <br /> Status <br /> Operational fit ` + Business Role Storage Typo <br /> _ p w+ <br /> (Fill one only) �i, (Fill all that apply) (Fill all that apply). <br /> m Active r Q Generator 0 Outdoor <br /> D Closed t �' c(✓6� <br /> GPS Latitude � , 0 r �� � a" +� s 0 Hauler 0 indoor <br /> t ar <br /> O Inactive (I <br /> 0 End Use 0 Container <br /> Longitude 0 Planned I+ �ti9rflt <br /> rn�,x e., t��t�!I��r rG»��«�I�a,,�� ��f ti . f r { <,: � n ,,: .!r,a_` _�.,_,•, �����c. _ ---' ------ _ L.�_... .. _- <br /> Q New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> `Used Tire Dealer 0 Auto Body Q Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire 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 /> 00 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 0 In Compliance - No Violations <br /> 0 0 Other: §�.._... _..._ _.-.. <br /> Comments (. <br /> Inspection Farm Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature_ Phone Number <br /> A_. 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: ✓ ;i11 =' f_ E 1 't <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> _4 <br />