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UrilUUgUg6b <br /> Waste Tire Su�ey & Inspection Repor Inspection Report Number <br /> State of California <br /> CIWMB181(New 04104) Survey Form - Page 1 Il - 1108442 <br /> California Integrated Waste Management Board — <br /> Part A- Survey BLU_E_O_ R BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- `` !! S I Inspection Type (Fill one) <br /> Site Suffix: �I I� �J � _ �0��� ® Q P Q Q <br /> Routine Re-inspection Referral Observation <br /> LocalI .T� t � coqf\ <br /> ( If Referral,choose referral type(Fill one) <br /> C 'Identifier: n V ,v1lIL Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or F ci ity Name <br /> Inspected By Inspector <br /> Physical Address <br /> 1119 I � 110 I L�n � <br /> iStrearU� —�. i�(�1 <br /> O^ Inspection Date Ila13 o <br /> C�-v -`-' S�ata Ua e Time In Time Out <br /> l <br /> Business Rep TitleI3 i O AM j ( 0 AM <br /> -- � 'II/ PM -; ' I � j0l OPM <br /> - Operational Status Tire Type Business Role Storage Type. <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ' Q le Active Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> -- - - Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business 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 Q Hauler Q Agriculture Q Shredder • Other 1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENT STATUS <br /> Q. <br /> iLVrAmHAULINGLANDxMANIFESITMREOUIREM ENMS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 014 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/C-IWMB 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 ® In Compliance - No Violations <br /> Q O Other: §,_- -_--- - <br /> Comments � !V,' _ .tnQ. 44� - — <br /> j <br /> _- <br /> Nt �- 1.�r ►-�- ups ll m�► i_�, u g A'MI r v�e, ,\fe La—e s. <br /> Inspection Form Included: Q <br /> Comments Included: Q41,sp Bus' e e Sig ature/ Phone Number r's Signature Phone Number <br /> INSTRUCTIONS ON ACK C rrec Incorrect: 33j EjXj Rf MI P jL I E[ I 1 k'2I 3 1 62081 <br /> White C y:CIW B Yellow Copy.Operator Pink Copy:LEA <br />