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::_ Waste Tire Sy & Inspection Repot Inspection Report Number <br /> kStati <br /> e of California _ <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I1 1143724 <br /> California Integrated Waste Management Board <br /> Part A- Survey -__ — _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPI - <br /> Site Inspection Type (Fill one) <br /> Site Suffix: 1 d 40 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: SU(1 (7C�qu�1� �(yUtlQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business ollr11Facility Name 1 Inspected By Inspector <br /> Physical Address l Y{en �5cob <br /> 1 set vN_ sc�,�.1t� <br /> c�• -��W <br /> � � 1 � <br /> S c 9S3oj Inspection Date v <br /> Time In Time Out <br /> Business Rep Titlei AM U 0 ® AM <br /> ' 3Q 0 P I O 1 l/ 0 P <br /> - <br /> Operational Status Tire Type Business Role Storage Type I <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)I <br /> S <br /> 4 Active ® Passenger * Generator • Outdoor <br /> 0 Q Closed ! Q Altered <br /> GPS Latitude Q Hauler I1 Indoor <br /> O Q Inactive ® Truck I <br /> Longitude — Q Planned Q OTR liQ End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 <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 <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date Q / m / m <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q I 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 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f 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 <br /> ®In Compliance - No Violations <br /> Q Q Other: § <br /> Comments �� <br /> -INt �. <br /> cal 1�L�1 Abse, �� GIpG- <br /> Inspection Form Included: QI' <br /> �{ <br /> Comments Included: ®; Z_/ / '� • g - +�17V <br /> Business Rep's Signature Rhone Number ( InSP is Signature Rhone Number <br /> X � /]I ���� 62081 <br /> INSTRUCTIONS ON BACK . Correct: Incorrect: � �_/! E X � h�4 P L � � � � <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />