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Inspection Report <br /> Waste Tire Su' y & Inspection Repori( Number <br /> State of California .� ■ <br /> COMB 181(New 04/04) Survey Form - Page 1 "5 - ;1 0 - 3 3 1 - <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- HE— <br /> Inspection Type (Fill one) <br /> Site Suffix: I <br /> —� - � t � (l�Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: r. i, t�-L�j,1( J CA <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name UInspected By Inspector <br /> Physical Address `'� — <br /> Street � <br /> ��� �J� r,��.� Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title m m O AM m : m O AM <br /> 1!'. / { (Vt foo I U I/1 m 0 'cy � PM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) IIIf�IIITIII 1111 J (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / y l�J f <br /> [k) Active 'O Passenger 0 Generator Q Outdoor <br /> GPS <br /> Latitude m m' 10 O Closed O Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive (e)Truck <br /> / Longitude — Q Planned Q OTR End-Use qD Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived <br /> l t i, (a <br /> = Fuel 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 Other <br /> I <br /> Part B - Inspection of WasteTire 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 O 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 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 /> Q O 14 CCR§1845_9.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 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 /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments / / I p <br /> {t it i 10 v(AfC /'f, l 't'1 �i , a Y 1/.'t0�� i ( t <br /> (� r {(tl l.r �� rf t r t7.� t• ) ((�ir � ''l (1 I'+i(Iv' ✓ f-It/ ( I J r( ! <br /> �li'PS , It V\.I(r-e AL, /<t C /''Ilt�. G'1�/t✓" C�. ftp/'', <br /> { <br /> �//r� ft e') Ely' f + ff✓ �l� 'f ��t�Y1 1 / �(!�� .L -� ~It�` �f fCli t4 /f/C'7'ri <br /> Inspection Form Included: Q <br /> Comments Included:O' - - - - ... :. . .. ----------------- <br /> Business <br /> ---Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> .� <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> ) ( , E� . M L I S <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />