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...._.::.. -- i...: _.. .. �[:.�:._:1....:."ill..:.....�'---_� _� t_�'_.dv_-rssx e•_..-'..w.... ...__. _ <br /> Inspection Report Number <br /> ill <br /> Waste Tire Survey & Inspection Rept,, t ■ <br /> State of California Il - 1140978 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> A- Survey - - - <br /> iness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) l <br /> Site Suffix: 1 to 2 <br /> { 4� J �_ � 9--- '-7 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` - \_ If Referral,choose referral type(Fill one) <br /> Identifier: A �Icz Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Bune <br /> siss or Facility Name v Inspected By Inspector <br /> Physical Address <br /> ,r� <br /> / q5-37--? Inspection Date 7 Q I <br /> �~ Time In c'c Time OutJ <br /> Business Rep Title O AM r O AM <br /> 3 CCj ®PM 3 ' 57 .� * Pm <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) <br /> Q Active Q Passenger ®Generator ® Outdoor <br /> ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive •Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> siness Type (Fill all that apply) _ --- <br /> New Tire Dealer p Auto Repair Trucking Fleet Q Government Q Retreader Q 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 Q Other – <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FENFORCEMENTSTATUS <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 / m / <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q . Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 /> 010 Other: § <br /> Comments <br /> i <br /> Inspection Form Included: 01 <br /> Comments Included:® Lei! - 1� ��r[�,' j1/ Aeor's <br /> ---- 6 ���Business Rep's SignaturePhone Number ure Phone Number <br /> • X 11 362081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � 1 , � 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> ■ <br />