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n-W <br /> Waste Tire -Sup Inspection Report ection Report Number A <br /> ■ . State of California _ _ _ t.�.. <br /> iiffaSi CIWMB 181(New 04104) Survey Form - Pagel <br /> - 10 ,2`5� 8 8 . <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' O1 1 1151 g � Q Routine O Re-inspection O Referral O Observation <br /> Local Z If Referral,choose referral type(Fill one) <br /> Identifier: Q� �tn C' � ,nf O CHP Q CIWMB O Compl4int Q Educational Visit Q'Other <br /> Business or Facility Name Inspected By Inspector <br /> I .1 Physical Addr ss 3 q – tol / 1 <br /> I �Q;rt r11 ` u t Z1 <br /> 38�f W Icoxo� <br /> Street <br /> 1-D <br /> /'� /� 63 S I � Inspection Date <br /> i City State ZIP Code Time In Time Out <br /> Business Rep Title T70AM Q AM <br /> Rick 1Aisi),h m 10 PM m � 0 P <br /> r€ Operational Status Tire Type Business Role Storage Type <br /> MOO (E) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Cdunt (WhOIe/PTE) Active Passenger (0 Generator IE) Outdoor <br /> Latitude <br /> , <br /> I <br /> GPS (E) Hauler 0. indoor <br /> _FFIO <br /> O Closed 0 Altered <br /> i Q Inactive Truck <br /> Longitude – Planned OTR Q End-Use Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer O Auto Repair 0 Trucking-Fleet Q Government Retreader Q Dismantler O Tire Derived Fuel <br /> i Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> i k Q Service Station Q Hauler Q Agriculture Q Shredder O Other I I <br /> --- ----- -- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ' A HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br />' O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> I <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q. O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 O 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 /> Q O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q O Other: § p <br /> Comments�A/ r.� J•/ � � G� b __ �,{ t � _J v+� � � � <br /> fYp� E' 11 Qrt--, CL`1—" --- v�"i_PY, (� toC � 'fir -i - ✓L� <br /> J y <br /> f <br /> BJP/ rllo)1 1.1 ht/ - (AtjPl- S10(eJ In 60 C 0f- 61C L Wrnr.fC4"t ; l! ; f(7 I�f 1ac�'t d' <br /> Df rC� �/PLif�i�f� l�f�r✓�C} f'►1Gtr11fy� .t5-t(7 m �_ 11'�.G,�P�Or. in ��1 �/iQydej, i'�avt;�� ,I '_� ftf7aki / <br /> 7 J <br /> 2 -,�. F� Pc _ ✓r�, ,. i/,,1- to vt e/ I""im 1 f t 6, �(t)m 0', .10 YI'ly✓5 ,�' `tom�l <br /> nspection Form Included: <br /> Comments Included: Cr '. !- �' V4. c l ': .l�•" . .. ..... <br /> 6Gsiness Re 's ignature Phone Number Inspector's.signature Phone Number <br /> v, 3 �; �,'���r <br /> INSTRUCTIONS ON BACK jCorrect:10 }(' �Incorrect: EP J_ E 1112 3 62081 <br /> ■ White Copy:CIWMB Yellow'Copy:Operator Pink Copy:LEA ® ■ <br />