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t Waste Tire ey & Inspection Re olb Inspection Report Number <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 I 1 - 1127587 <br /> CalL.ifornia Integrated Waste Management Board ------ i <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- FUO <br /> fy15 Inspection Type (Fill one) <br /> Suffix Site Sux: `f 'CD Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SA 0 �O� �1 n ��L� n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> FBusiness or Facility Name <br /> �Ao c'v�` l Inspected By Inspector r� <br /> Physical Address <br /> F30 0 � � <br /> �1 l <br /> t L� UA5l, N, NA A � <br /> Street <br /> Inspection DateC � <br /> F) <br /> I <br /> } <br /> 1 <br /> City State ZIP Code Time InTime Out L Business Re P Title PM , O0 AM <br /> PM <br /> io d-0-f r <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ❑ L_Ebl (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Passenger 13 Generator 15 Outdoor <br /> GPS <br /> Latitude m�O Q Closed Q Altered <br /> • Q Hauler (D Indoor <br /> O Q Inactive Q Truck <br /> =17-1 <br /> Longitude - =1 - Q Planned Q OTR Q End-Use ! Container <br /> Business Type (Fill all that apply) _ <br /> .0 New Tire Dealer Q Auto Repair Q 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 I I <br /> Part B - Inspection of Waste Tire.Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 'HAULING AND MANIFEST REQUIREMENTS <br /> 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 m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date W / M./ <br /> 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 T <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 (Q In Compliance - No Violations <br /> Q Q Other: § <br /> 7 <br /> Comments U4\aL <br /> ]n L J IOR r4m, GA t , rtC� <br /> �G,r�'�f �� U� (umc �('n� Icer Ali <br /> Inspection Form"Included <br /> Comments Included. Q .._ _ 'f ._ •._ _C._J._ z '. 4 _;~, ° ,/21�.��_ <br /> Business Rep's Signature PhoneNumberInspector's Signature Phnne Number r <br /> INSTRUCTIONS ON BACK ,Correct:• Incorrect: X ,A N) f i�� 1 2. 3 62081 <br /> - -- <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />