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Waste Tire SO✓e & Inspection Repo Inspection Repurt Number <br /> z y I1 - 1088246 <br /> W�1 � State of California <br /> CIWMB 181(New04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey -' - - - - <br /> Inspection Details <br /> Business Pr, 'le - - ---- - 7 <br /> TPID- _ Inspection Type (Fill one) <br />} Site Suffix: r '4 V �Li �� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> SGC\ ToCAC + 11C1 tUtnt T Q <br /> i Identifier: � 1 � Q CHP Q CIWMB Q Complaint Q Educational Visit Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> F-1=C) <br /> Physical Alress <br /> Street Inspection Date V �jE21 <br /> / ' <br /> C X356 �JJJ <br /> ' I"I <br /> N1 c�rhe C-t In Time Out <br /> _. _ <br /> -,. `�—-. State ZIP Codi Time..__.__ <br /> Business Rep Title AM <br /> �_...__�_._...,� • O PM E-E] • O PM <br /> Operational Status Tire Type Business Role r Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire County,Who1, JPT <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> - _ p <br /> Q Closed Q Altered <br /> GPS Latitude ,{ Q Hauler Q Indoor <br /> LLLI— O ® Inactive Q Truck <br /> Longitude F�—T-1 • 7_1 Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V'A THAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§X12951 -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 /> R 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CC § 9 <br /> Q Q (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 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/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 ThGeneratorse � In Compliance - No Violations <br /> O O Other: § <br /> Comments �y w <br /> U �'\C�'-.z_ ��o� _�2` _t1�. sGL111 _J��h i.��j�[r�C sSY� <br /> 1 <br /> er �tnYtS fio I�� U M t�IeT 93 LckA—hra__�; �_� `1�' T -11_�' {�dGo_4 <br /> o Y <br /> Inspection Form Included: <br /> Comments Included: Q` - <br /> t ln, ec ori Signature <br /> - ' Phone Number i <br /> - _ <br /> Busi�iess Rep's Signature Phone Number; - 4 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X � A�.M P L E 1 23 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> ILe <br />