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W °ste Tire SLAB & Inspection Re -b Inspection Report Number- ' <br /> • .,&&� �' State f California !. - I— �. ■ <br /> CIWMB 181(New 04104)mSurvey Form - Page 1 1 7 . 0. 1 7 3' 9 <br /> California Integrated Waste Management Board ; <br /> Part A- Survey %'}N BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detailp, <br /> TPID- n Inspection type ( ill one) <br /> Site Suffix: <br /> 0 (0 Routine Q Re inspection Q Referral Q Observation <br /> a <br /> Local r I If Referral,choose referral type(Fill one) <br /> Identifier: �(�� ( f(` (�(r� GC a' I IO CHP 0 CIWMB `,O Complaint O Educational Visit O Other <br /> Business or Facility Name f Inspected By Inspector <br /> Physical Address +� 1 I Jaw Al r0 <br /> Street I <br /> Inspection Date <br /> City State ZIP Code ' Time In Time Out <br /> Business Rep Title O AM Q AM <br /> [T]!j ��>> QPM 1= 0 P <br /> *i i I�-t ol &&oc 1voo-7, Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 11 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( Active Passenger Generator <br /> g � � Outdoor <br /> O O Closed 0 Altered <br /> GPS Latitude m • ® Hauler 0 Indoor <br /> O 0 Inactive gD Truck <br /> Longitude — O Planned 15 OTR End-Use Container <br /> Business Type (Fill all that apply) <br /> d w Tire Dealer Q Auto Repair O Trucking Fleet Q Government Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> O Service Station (E) Hauler O Agriculture Q Shredder O Other L <br /> Part Br Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A i HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O 'Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline I <br /> Q_ Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> O 0 14 CCR§18459.1'(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> .0 O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O I@ 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (F) In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> lei l�l}][1.0t.Y.(( k)n / It,��`'�f�� (�li{ -ro�" tt / ` <br /> ��'i r �^C G t ;t f0 (c r't� (r'{�0 (4, ``"(JI C-T-L n.v�4 1, k; <br /> I, ��i ; i/!eiv/rf . _.l dig r rt C°t c _1 rpa i i Qty` t' �-IGt t �CK, r- -�/r r(( {,r(,(r I y <br /> _-11114i <br /> nspection Form Included �r <br /> Comments Included. t. - , _�_ I.,.t" <br /> Business Rep's Signature Phone Number/ Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X i� E XI.AIM I P IL � L � 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />