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Waste Tire Suy & Inspection Repo Inspection Report Number ■ <br /> CStateIWMO 181(New Form - Page 1 11 - 1088230 <br /> CIWMB 161(New 04/04) Survey g <br /> California Integrated Waste Management Board <br /> ryBLUE OR BLACK INK PEN <br /> Part A Sue <br /> BusmesProtl�a ,Inspecti�an Details - - <br /> PID- --7 1 j �I p f Inspection Type (Fill one) <br /> Site uffix: jL <br /> [ ( .� - �� @ Routine Q Re-inspection Q Referral Q Observation <br /> .� If Referral,choose referral type(Fill one) <br /> Local �jAY\ �Oc+ ) COU i c <br /> Identifier: �LII ,� � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address a � 6 Kr ► I an <br /> Street , <br /> Inspection Date i � } ' ' y � � 1o181 <br /> q52 <br /> _ 9 Time I Time Out <br /> Stale 7IF Code _ -...- ... —. <br /> Business Rep Title 0 AM 0 AM <br /> O PM ' O PM <br /> Iped fOff,rA A t J � —}L - - g Type <br /> __. <br /> UWner p ( TypeppY)r <br /> Operational Status Tire Business Role Storage T e <br /> (Fill one only) Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> Tire Count(Whole/PTE) I <br /> OActive O Passenger O Generator O <br /> Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude , Q Hauler Q Indoor <br /> Q Inactive Q Truck , <br /> Longitude - Q Planned Q OTR <br /> Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer @ Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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/ I ATHAULING AND MANIFEST REQUIREMENTS 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / E] <br /> 14 CCR 18459.1 -Tire Program ID Number from CIWMB <br /> QQ § 9 <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> - — _ -- - - - <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 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 /> O O Other: § - <br /> Comments <br /> lon _-p�e,r�dYme.r� -fll1�:�1a-1'e `� -�n�._ o1_toW�r�� Was nod-ems- '• <br /> X10 7117 c�'ov4e on- �-E2 . _ _nrCC ckt 0CC, d4-' T <br /> Ick-\-rr T wct'� � ��� d�vlc�eca 1gpC 1 ofd ,vAv <br /> I r y trr Y` C <br /> Inspection Form Included: Q a <br /> Comments Included: <br /> OI,Buslness Rep's Signature Rhone Numkaer Ins char s Stgnature Phone Number <br /> - - 62081 ; <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X + ' �_ E!_ t " <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />