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Ok <br /> o; . Waste Tire S & Inspection RepoSpection Report Number r® <br /> ■ *CSA <br /> e ' State of California . <br /> cn <br /> CIWMB 181(New 04104) Suivey Form,- Page 1 Il _ 108'8006 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile .a i Inspection Details <br /> TPI <br /> Site ffi <br /> - �} Q _ Eul <br /> Inspection Type (Fill one) <br /> Site Sux: � t V d ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ;O �,� Cc�un� If Referral,choose referral type(Fill one) <br /> Identifier: JGn � y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ Inspected By Inspector <br /> i Br uQ.lz�) Sod v ShU� i <br /> Physical Address i a _ dI KniAl(An LU C.Q. I <br /> 2-SH 8 N. vJi\son «)au -1 <br /> Street <br /> Inspection Date <br /> �S-�OC K+o n CA 9 sz,a5 , <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title m O AM O AM <br /> 0PM m . m 0PM <br /> an M c D nw 11 Nt a n a e.r- I <br /> Operational Status Tire Type Business Role Storage Type <br /> r- (fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count Whole/PTE 2`1 <br /> 1 f <br /> l� ® Active ® Passenger ® Generator Outdoor <br /> • O Q Closed ®Altered Q Hauler Q Indoor <br /> GPS ' Latitude EE] . <br /> ❑ a, <br /> 1710 <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container ti• <br /> Business Type (Fill all that apply) �"- <br /> v, <br /> Q New Tire Dealer Q,Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler -Q-Tire Derived Fuel <br /> Q Used Tire Dealer # 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 /> - --- -- ---- <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS `'' <br /> V A 'HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extensio <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 i <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date ' / <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB i / <br /> Q Q .- <br /> — (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 =Submittal of Comprehensive Trip Logs within 90 days t' <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years - <br /> Q I Q 14 CCR§18460.2 Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> I0 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 <br /> In Compliance - No Violations <br /> Q Q Other: § <br /> Comments �OUtkfxe I ra,Pk C* C�U'C --�o 116U,! <br /> GGT _ u�eS Vic,_ 1�Q `rt(e �-pasq� a ate e rems�Yr�Y �. r �c <br /> f'Y an lTeS)id ev Cl.,.. -T -f 17; CSn!'�'1 <br /> Nc��JAPaYe Qs Q C o nc <br /> Inspection Form Included. Q <br /> - - <br /> A i natPhone Number Comments Included: Q - �- _32Business Rep's Signature Phone Number9 <br /> - ---— -- 62081 w. <br /> INSTRUCTIONS ON BACK { Correct: incorrect: ( J "t P t E � � � <br /> • Yellow Co Operator Pink Co LEA `` <br /> e White Copy°CIWMB Py:. P Py t <br /> L- <br />