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® Waste The S & Inspection Repor Inspection Report Number <br /> LSBff State California <br /> CIWMB 181(New 04/04) Survey Fora - Page 1 11 — 1127642 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> inspection retails <br />} <br /> Business lProfile <br /> � a rQ Inspection Type (Fill one) <br /> Site Suffi -inspection <br /> ection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. � � _ (Jt 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t Inspected By Inspector <br /> Physical �---Address -�— / /� C✓ L1 <br /> atre�c, � <br /> Inspection Date <br /> � ! <br /> _--_ - ✓ ` Time In Time Out <br /> St ,rw . , ...... <br /> Business Rep i O AM <br /> I AM <br /> Title E O �_. 4 L. 0 PM O PM <br /> 4M <br /> Q � - -- <br /> Operational Status Tire Tyke Business Role Storax Type <br /> (Fill one only) (Fill ail that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) y of <br /> -igen Q Generator Q Outdo <br /> Q Active Q Passer <br /> D Q Closed Q Altered <br /> GPS Latitude ( Q Hauler Q Indoor <br /> - Q Inactive Q Truck <br /> —7 0 <br /> Longitude - ( Q Planned Q 0Ti <br /> Q End-Use Q Container <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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other 471j.tom !2&r f <br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS �� �� <br /> Part B - - <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension' <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <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 /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q 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 ' � C <br /> LA <br /> Inspection Form Included: Q` �� a. ;:� � w x . � av <br /> Comments Included: Q <br /> Business Rap's Signature Phone Number ins{➢ratnr.>Signature Phone SaltM"aer _ <br /> A. -1 8?-681 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X ��A AA<=' L <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA � ■ <br />