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t <br /> Waste Tire SuNvy & Inspection Report aspection Report Number <br /> State rlfl <br /> CIWMB181(NewCaliforniS��p Form — Page 1 <br /> CIWMB 181(New 04104) V ��iiy g I 1 - 1143576 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> `A- Survey____ <br /> ness Profile Inspection Details <br /> ,.-ID- - O Inspection Type (Fill one) <br /> Site Suffix: 3 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local M If Referral,choose referral type(Fill one) <br /> Identifier: �(��Q"W� .(i� - - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 4 Inspected By Inspector <br /> Co 1`1.�. �Cu.(.��1 n p p <br /> Physical Address I O I Ren E5� <br /> AV � Ave'. -- - - — <br /> Inspection Date <br /> Sdon CA q5�5 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 3 • QPM 1 ' V 41PM <br /> — - -- - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ®( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 3 3 Q Active Q Passenger ® Generator Q Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude N1 A Q Hauler 1 Q Indoo�� <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Jew Tire Dealer Q Auto Repair S Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 i ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste 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 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 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 - - --- <br /> 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 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 S In Compliance - No Violations <br /> Q Q Other: <br /> Comments �n���(6` 1(1G�C,(�,Q�(�l_u�.• ���\'S �U,�eJ Cin C.�t)1 ��k',—��5�-1�e� . <br /> C'.1 i r 1- G -0 eol,YN <br /> ,rection Form Included: O <br /> ! SAY cl) -31`7 <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number 4p ,,r,4gna u r e hone Number, <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �/iX �4 J F j (R 111 i 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />