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�k <br /> ■ Waste Tire-Sy & Inspection Reporinspection Report Number ■ <br /> CaliforniaW5, <br /> +L State of California <br /> . Survey Form - Page 1 Il - 1088021 <br /> j CIWMB 181(New 04/04) <br /> ifornIntegrated Waste Management Board - - <br /> Business P atf a BLUE OR BLACK INK PEN <br /> " ""$"°' ` i„ -` �' 7""; u� Inspection petals <br /> _ <br /> te Suffix. i t 3 [.7 <br /> �Z I � r> ( f Inspection Type (Fill one) <br /> S <br /> C� 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S Gn Toclquin coun�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> r� J ca�}__-Co n+ ne r _ C-T r� u� � [C-i <br /> p <br /> Physical Address <br /> J — <br /> 1985 W. YOSemt,t-e. Ave_- --- <br /> Street (- <br /> .2 Inspection Date ' (n I / 1_0E / LO <br /> L�] <br /> State ZiFJode Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> Li I • LL 0 PM � ' �— 0 PM <br /> Cif 6 FeC'ncrnd QSd _�.n <br /> ",,,� ,� ��(r,)t, , ""� �,� Operational Status 't"ype Business Role Storage Type <br /> e (Fill one only) (Fill all that apply)1 (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ! d <br /> 0 Closed 0 Passed g Generator 0Outdoor <br /> I _ _ <br /> Active Passenger <br /> IJ <br /> GPS Latitude O 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <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 L <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other `. ��r�p�, De F> ) <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 <br /> 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 m / 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/CIWMB Enforcement <br /> 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 <br /> L10 In Compliance - No Violations <br /> 0 0 Other: § _ —-- ( - - <br /> Comments QR O�YWc'.0 1 Y11 doAz_-�� � 0 oW i ncj... wCIS_n9fed <br /> /\PPro .- ILi WQste 06e6 �re� 'ore4 �Y) c_o>*a�ner���gn-5�_te- _1FaC._v1_&y <br /> CTL <br /> r r.:> t� , �". ;vQ V\0ku+fit-onz or -art0l D�_ concern. <br /> inspection Form Included: 0 <br /> 44 Iry 31 <br /> Comments included: 0 <br /> Business Rep's Signature_ Phone Number ,,,Hispector s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: z §; #�, � i P I l- E 1 2 3 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />