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® ' Waste Tire Su & Inspection Repoi- pection Report Number <br /> ■ <br /> StateCaliforniaMSurvey Form - Page 1 I 1 - 1088023 <br /> CIWMB 181(New 04/04) <br /> California Integrateded WasteteManagement Board <br /> Part-A- Survey BLUE_ OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ( I U v I 1 Z 4� <br /> QRoutine QRe-ins Re-inspection <br /> Q Referral Observation <br /> Localc y If Referral,choose referral type(Fill one) <br /> q� �O <br /> Identifier: J aq u i n LOU R 1 j QCHP QCIWMB QCom Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Addres� �u — Q1 ����. al1C _� f ( <br /> 16 -- <br /> L. 15 Z57 <br /> Street <br /> An-{- /' i Inspection Date <br /> 3 b It <br /> a <br /> y. <br /> "rt1 e.Cq _._�- C Stat -- Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> '!OPMIopm <br /> Operational Status Tire Type Business Role Storage Type <br /> (� a (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply)'. <br /> t8 a <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> I p Q Closed Q Altered <br /> GPS Latitude <br /> Q Hauler Q Indoor <br /> OQ Inactive � Trck <br /> Longitude F7 <br /> BBB -Use QGontalnerQ Planned Q OTR End <br /> Business Type-(Ftil all that apply)' <br /> Q New Tire Dealer ® Auto Repair 0-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 FORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS - - -- - - EN - - - --- <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 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 Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> -- - — __ <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 Tire Generators <br /> In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> - <br /> Fac.► kV I r,ZL j -i-G, tie �_Ala.t- +IX-e - <br /> 'C'�� feel I e - <br /> Inspection Fonar Included: tf t <br /> � I <br /> Comments Incleaded: Q Business Rep's Signature Phone Number or's Sign�ature� Phone Number <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: 62081 <br /> �I <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />