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Waste Tire Su, vey & Inspection Repor, Inspection Report Number ■ <br /> ka State of California Il - 1143984 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> aAe-- Profile -__Llnspecti- Details - - I <br /> - BLUE OR BLACK INK PEN <br /> -- - - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: L� L� l - ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � ` �� v�� �(�t/Y( /�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address © l i9 l y FT7(,LM 6_1 <br /> Inspection Date 0 —7 <br /> C/ v <br /> Time In Time Out <br /> Business Rep Title <br /> • ® AM 40 AM <br /> �Q � 0 0 PM V) �� 0 PM <br /> - <br /> _. Operational Status Tire Type Business Role Storage Type <br /> ,ry (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 /> ®Closed Q Altered AIIA 1111A <br /> GPS Latitude I :*'1A Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> ;iness Type (Fill all that apply) _ _-__- <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> V 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 <br /> Part B- Inspection of Waste Tire Dealer, Generator Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V-1 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 / m / 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 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 /> Q Q Other: § -- - <br /> Comments <br /> inspection Form Included: <br /> Zo7 3J G1� _ o z-YG -YG <br /> Comments Included: - - - ------- tors lure Phone Number <br /> 1,Business R 's Signa ure Phone Number P 9 <br /> --_ 62081 <br /> INSTRUCTIONS ON BACK I Correct:I* Incorrect: X ; <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />