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Waste Tire Su Inspection Report * tion Report Number <br /> CIWMStateB <br /> f 81(New <br /> Survey Form - Page 1 3 - 1 0 7 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> 'art A- Surve BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- I I I G1 Inspection Type (Fill one) <br /> Site Suffix: n I — <br /> t @ Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: S, \ U.;j 1rt 1 ( �Vt_+ \ �j 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name U Inspected By Inspector <br /> Love IeAce_ 7rAY, I' ut <br /> Physical Address <br /> 7, J L c e <br /> Street <br /> � Inspection Date <br /> City State ZIP Cade Time In Time Out <br /> Business Rep Title I I : f Q AM I : I Q AM <br /> Al-t ( I! QPM Q PM <br /> p. <br /> �7 re �OUnt(Whole/PTE) <br /> Operational <br /> ononly)Status (Fill apply) ((Fillll all that apply) (Fill all thatsiness Role Storage pe <br /> apply) <br /> pply) <br /> I (f� ( Y) ( ,,th Pp <br /> . m .�... ;...,, . <br /> ®Active (� Passenger 0 Generator 0 Outdoor <br /> /"nil, i;.�mi�r Jill,11111 e� <br /> GPS Latitude I • I I" 0 Closed 0 Altered O 0 <br /> Hauler Indoor <br /> 0 Inactive 0 True <br /> IIII ! <br /> Longitude — 0 Planned 0 OTR ® se 0 Container' <br /> Ipy End-Use <br /> Business Type (Fill al that apply) �� ' , <br /> Ir; <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 (D Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder (2 Other I W4,? 11��r1(>✓,;r E/: e'a;r ��yl a; <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 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 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire 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 /> 0 0 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 0 In Compliance - No Violations <br /> 0 0 Other: §. --__— <br /> Comments `,, rirQ ,"O F 1td ar^C'� V1lu;t F al�pht U• Wt r l l+ <br /> , <br /> tin1 <br /> ter, j1av l+cct (it, WC4(1 t e f,0Vp ,,1 Itme ,�- o I L)V) S Kj-er <br /> 7 r. /�1QY1, t/ar 1c, rDr y(-lar 5 . No V, 0 ��. f!'u�1 C <br /> Inspection Form Included: 0 .. <br /> Comments Included: 0' - -' <br /> Business Reps Signature Phone Number <br /> X � / l I I M 1 1 11 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �✓ i'e 7C R MR �` � .� 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />