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®` Waste Tire shy & Inspection RepolnspectionReportNumber <br /> State of California ■ <br /> CIWMB 181(New 04/04) S u rve Form - Pae 1 Il - 1086912 <br /> California Integrated Waste Management Board y J <br /> mus Hess P o tie' �'t Inspection Details - BLUE-OR BLACK INK PEN <br /> } TPID- Inspection Type (Fill one) <br /> Site Suffix: Em V r Q <br /> ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: it (�, l�Ct I C r <br /> J 1 i• 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit Other <br /> Business or Facility Name - <br /> Inspected <br /> By Ynspector <br /> a , , <br /> Physical Address — � - -� 3Ld <br /> - lir, <br /> l <br /> �c; r <br /> Street <br /> Inspection DateMPJR <br /> / -Ul fl <br /> ItV State ZIP Code Time In Time Out <br /> _J�Business Rep _ Title 0 AM l 0 AM <br /> n4. c _ Irl <br /> — Operational Status Business Role ! Storage Type <br /> Fr sk ✓. i s r, P r k'k V I. 1 <br /> ( ;� (Fill one only) � ,�, (Fill all that apply) , (FiU all that apply)I <br /> The Count(Wh6lelPTEj2 <br /> r ✓ ;" '✓i f a, i>.2, ,r„r,.a.. ® Active ,u <br /> Generator 1 0Outdoor <br /> D0 Closed <br /> GPS Latitude Hauler Indoor"� ' <br /> o 0 Inactive <br /> �� <br /> Longitude - 0 Planned I',rr 0 End-Use Container' <br /> Business Type` (Fill all )�A , , W. <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 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 <br /> 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 -Tire Program ID Number from CIWMB <br /> 0 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 /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 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 In Compliance - No Violations <br /> 0 0 (Other: § <br /> Comments <br /> o <br /> i <br /> oInspection Form i Included: <br /> Comments Included: O ✓ ?' <br /> i Business Rep's Signature Phone Number Inspector's Signature ! 'Phone plumber <br /> - 62081 _ <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ' <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �(^� <br />