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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I 1 - 1143567 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> t A---Survey_---- ,-------- <br /> iness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Lk 6 L 3 D_ 1 --- O ( 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local T r, If Referral,choose referral type(Fill one) <br /> Identifier. S(!yrs V 0 1A�`n W lA � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name? Inspected By Inspector <br /> Physi� vc.Address 0c�(\k <br /> calo <br /> 11000 E. (r C'_4 L:ne.. CIA, � SL�Ve__ <br /> C 53b'1 Inspection Date a L b <br /> ftk-C Time In Time Out <br /> Business Rep Title � 0 O AM r0 AM <br /> 1 � O � PM <br /> V • PM a� <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) 1 <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O- •Closed Q Altered N/A N10 <br /> GPS Latitude N Q Hauler Q Indoor <br /> O Q Inactive Q Truck A <br /> Longitude - Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> U 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 /> ------ - ---- —-- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> — <br /> V A HAULING AND MANIFEST REQUIREMENTS 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. 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 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 1 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 In Compliance - No Violations <br /> 0 , 0 Other: § 1 <br /> Comments d n ��15 UTc v4u-� x A q W 4 S(1 CfC <br /> - cA-- Fa, �AAI)-lA)n An'k 1S n0 I_ f i i S�— <br /> V <br /> Inspection Form Included: QI �I o <br /> 0 <br /> Comments Included: Q, --- <br /> Inspect s Signature h <br /> Business Rep's Signature Phone Number one Number <br /> - -- - <br /> ----— --- — 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect V) 1 �- L <br /> 1 2-t3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />