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M -jMWaste Tire Su :y & Inspection Report Ispection Report Number <br /> State of California I 1 - 1140719 <br /> CIWMB 181(New Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: L) 3 n� ' ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1� - <br /> C Inspected By Inspector <br /> C Pr vv\0 I'i YC S <br /> Physical Address ?J 9 <br /> /�rnhcwe(ti gvt�•c� <br /> Z <br /> Inspection Date () - oZ 7 / f O <br /> �Sc��7vti C-A 91-32-C) <br /> Time In Time Out <br /> Business Rep / Q Title _ 0 AM _ 0 AM <br /> N <br /> rZC� L C7 U 0 PM U Z 0 ® PM <br /> vl-o,r �c�,t lir ��.vrtar- - - - <br /> --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) S (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger ®Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> D 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> - <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 0 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 <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 /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date[T] / M / m <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 I 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 /> Other: § - <br /> Comments <br /> L1�li� �.5�[Q�1GN�-• CSY�� �•C �Qt�-C.T � �j��CJI�-I t,� <br /> AID <br /> / i�n-frc:r� �D r <br /> .Inspection Form Included: 0 / <br /> Comments Included: QI I - - cn!/�, _ 051 V6-9-06 <br /> Business Rep's Signature Phone Number/ nspector's Sig ature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: x �,. �/ A p 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co <br />