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1 <br /> Waste Tire Suy & Inspection Repor4_0lnspection Report Number <br /> State of California -- ■ <br /> California CIWMB 181(New Survey Form - Page 1 I 1 - 1088186 <br /> Waste Management Board <br /> Integrated <br /> Part A Survey <br /> BLUE OR BLACK INK PEN <br /> Business Praffle� p Ins ection Details -- <br /> TPID- ( n Inspection Type (Fill one) <br /> Site Suffix: -I Q - 1_9�1 <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local IS <br /> 'If Referral,choose referral type(Fill one) <br /> Identifier: Ca n 7Q G q l:U In QU rl t i <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Au-1-o - <br /> - �� J', Inspected By Inspector <br /> ,ysical�S a ress <br /> oh � truck —�� —3_q_ _ P <br /> -� I <br /> �_._�....._......._� LKf ISA I cnn Lc+c G s j <br /> I 1 G Z>j TrA 0>1 Ave <br /> Street `�3z p � _ <br /> Inspection Date <br /> ��seal Gh _ , _ d O <br /> City State Tip Code Time Out <br /> Business Rep Time In _. O AM 1 . I O AM <br /> Title dl', PM <br /> 0 PM <br /> .l General Mc-r. <br /> ��- <br /> Operational Status Tire Type ype Business Role Storage Type <br /> i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> 8 Closed Q Altered <br /> GPS Latitude Q Hauler Closed <br /> Indoor <br /> -T- <br /> 0 Inactive Truck Q <br /> Longitude iJ <br /> • T7 Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government QRetreader QDismantler <br /> Q Tire Derived Fuel i <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 i HAULING AND MANIFEST REQUIREMENTS <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 I Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q I Q 44 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 1 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 /> outtRe �n�>Rec�►gin Dar�Ur,me,d 41S do-ben tS n <br /> t z �n <br /> �..- a k n v <br /> CIA g57:;2U is ctn Qct►y ne.ss in gaod `..AanclIY)4 under 7"P1'D site <br /> v J <br /> S5 AA 1Z 8$ col , Thm -7plc) I— 1 031 <br /> i jamCo Cztnty IS (, a ott: QBusiness Rep's" Signature Phone Number Yspectors Sign r .. <br /> ,^ Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081AWPL Ti f i <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA t <br />