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10328050020 <br /> Waste Tire Survey & Inspection Report. Inspection Report Number ■ <br /> 181 <br /> La State ofCalifornia I 1 - 114 0 5 6 9 <br /> CIWMB 181(New nage Survey Form - Page 1 - <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection TypeFilt one <br /> Site Suffix: . R-51 <br /> IR <br /> Fo f1 ®Routine Re-inspectionOQ Referral Q <br /> Observation <br /> Local1CD If Referral,choose referral type(Fill one) <br /> Identifier: �Ckn �0 LAI n (1^ Q CHP Q CIWMB Q Complaint . Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical A ress 3 ( V 1 <br /> Street <br /> Inspection Date <br /> J_Aa n ��1 I 5 .15 I <br /> City State ,ZIP Code Time In Time Out MIS <br /> Business Rep Title 0 A �. 0 AM <br /> 0PM ,ajSPM <br /> _ 1w!`Cr�— <br /> ---- - _ - � Operational Status Tire Type Business Role . Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � I. '^ <br /> ' t1/ Q Active 0 Passenger 0 Generator jj Outdoor <br /> j I ® Closed Q Altered <br /> Latitude <br /> GPS ' ., j , Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Ii I I IQ Planned •OTR . Q Container.Longitude Q End-Use <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader p 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 A Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler:and End-Use-Facility ENFORCEMENT S1TAT1US <br /> -'SIM LING 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. Compllance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> .0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 DCl) <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 1 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 ® in Compliance - No Violations <br /> Q Q Other: § <br /> Comments n 1 1 A I_1Ju(AS1c - 1_fc.1_Q-• r ��" - _ iL1��` ] C—(�Qj� <br /> n <br /> alra �t2n3 <br /> Inspection Form Included: Q II <br /> Comments Included -- <br /> Business Rep's,Sigriaturfi Phone Number INSP,_ <br /> nr�sigj_-^aw�e Phone:Number <br /> INSTRUCTIONS ON BACK Corr cf: correct:. , EIX RIM► P L 2 3 62081 <br /> White Copy CIW Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> I <br />