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Waste Tire Su, Bey & Inspection Report Inspection Report Number ■ <br /> eCd State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I 1 - 1127737 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection� ^ Inspection Type (Fill one) <br /> Site Suffix: J 5_1 <br /> � ( Q Routine • Re-inspection Q Referral Q Observation <br /> Local ,A If Referral,choose referral type(Fill one) <br /> Identifier: S(kA Iso(,(,L(ui f1 COVI VI O CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name L J <br /> Inspected By Inspector <br /> - <br /> Physical Address 3 9 i l EwR <br /> Inspection Date � / <br /> S-~o c1rcA6 C A 95X5 O 0 `� <br /> Time In Time Out <br /> Business Rep Title q AM f) AM <br /> 1 0 P 5 0PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 b <br /> ®Active Passenger 10 Generator Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude O Hauler O Indoor <br /> 0 O Inactive 0 Truck <br /> Longitude — O End Use Q Container <br /> O Planned OTR <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder • Other Vt►1j G 12./Egltjp <br /> 1. �" <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 /> 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 <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> (Required for NOV or EXT) <br /> O O - - - --- - - -- <br /> 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 0 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 /> O Q li Other: § <br /> Comments N.1 0 1 I n <br /> A Wks <br /> X19 -,J ► o\(kV X'Ong b s u.sa,& Ct IC001CUn . - - ---- <br /> Inspection Form Included: O 1 <br /> Comments Included: — - -, --- -- - �r'�sSignatMt <br /> - <br /> Comments <br /> Reps Si nature Phone Number Inspeure Phone Number <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect E X A M la L i E l III <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />