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Waste Tire S y & Inspection Reporl0Inspection Report Number ■ <br /> State of California I <br /> CIWMB 181 New 04/04) S u rve Form - Page 1 i ; ' 7 <br /> California Integrated Waste Management Board Y - - - <br /> Part A- Sury _ BLUE OR BLACK INK PEN <br /> Bustnessproffle Inspectop Details <br /> TPID- - e Inspection Type (Fill one) <br /> Site Suffix: 9 l ✓' �� r <br /> p X I t Routine Q Re-inspection Q Referral Q Observation <br /> Local — / + If Referral,choose referral type(Fill one) <br /> Identifier: --;,/nUy Al( f: r'-' <br /> � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> -d Physical Address - ---� - <br /> AIA I AJ <br /> Street <br /> (� tC✓1 CA 5 7 7 65 Inspection Date �TJ�1 ( / ( ! C� -_�_1 <br /> I <br /> Time In Time Out <br /> C,'ity l State ZIP Coda <br /> Business Rep Title �0 AM Q AM 0 PM F, <br /> 0 PM <br /> --- —i> <br /> Operational Status Tire Type Business Role Storage Type ' <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - T ` Q Planned Q OTR 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 /> 6) 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 <br /> Facility NOR- <br /> f liAT <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> OeOVoao 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 Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> Q 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 (V 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 I 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 In Compliance - No Violations <br /> Q Q (Other: § <br /> Comments /�/� <br /> I ,' . yr� -� >r;l If 111`4e el <br /> / r f l a t". <br /> lrA N1✓5J L r P/LI f /teJi r s- r r r t7 r.11JllLfG! Cl g-t 1�L t�� 'a! K(' c'ee- t- _ <br /> i? <br /> Inspection Form Included. b <br /> ,00 1 0"1" <br /> Comments Included: 0, <br /> Business Rep's Signature Phone Number Inspectors Signature Phone umber <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ,hr, tl 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © 0 <br />