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® Waste Tire SU�y � OrISpeGt!®r4 Re (yr Inspection Report Number <br /> State of California - <br /> a� Survey Form - Page 1 I 1 1127632 <br /> CIWMB 181(New 04/04) — <br /> Cahfornia Integrated Waste Management Board <br /> Part A- Survey ..._BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- fd' i^`7 Inspection Type (Fill one) „ <br /> Site Suffix aj J U - <br /> Referral Q <br /> Routine Q Re-inspection Q RefObservation <br /> Local r— If Referral,choose referral type(Fill one) <br /> Identifier: r <br /> { l <br /> — .L� CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — <br /> Inspected By Inspector <br /> E <br /> Physical Address <br /> 5 reei / v ' {�CGt_ �f ,. .. .. ..... Inspection Date �! _r I <br /> Business <br /> a/ts Zip";cuje� Time In Time Out <br /> siness Rep Title 0 AM j f 0 AM <br /> =0PM �.� I ( l it l '' 0P <br /> �Y.1�i7 t CA I ll G.�` z r 7u r' ._ <br /> Operational Status Tire Type Business Role Storage Type <br /> The <br /> (Fill one only) (Fill all that (Fill all that apply) Fill all that @,p I y Pp v) ( u v) <br /> IS Active Passenger Q Generator Q Outdoor <br /> Closed <br /> �iPs Latitude I Q 0 Altored <br /> F Q Hauler Q_indoor <br /> I -- Q Inactive Q Titick.......... <br /> Longitude Q Planned Q OTR Q End-Use 0 Container: <br /> ;n <br /> Busines Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 <br /> 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 HAULING AND MANIFEST REQUIREMENTS <br /> — -- — ----_--i— ---- ---- --.. ----- Q Notice Of Violation <br /> Q ExtensionQ Q PRC§42951 -Waste <br /> 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 O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date / <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 /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 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 /> Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> 'q 1 l 4 v -11're .{� <br /> �it1 Q S /1 Df P _ Yt e c 5 qqo a AI ey <br /> Sp L�S . no-) *res , fi4 L 1 I� <br /> Inspection Form Included: Q <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Ills pectcr>Sign�t�rr� � Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X Ak620 <br /> ° <br /> �, £31 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />