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03217040085 <br /> Waste Tire Survey & Inspection .Report Inspection Report Number <br /> 119. <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 1 9 - 10 7 9 3 7 1 <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. fl 40 Routine Q.Re-inspection Q Referral Q Observation <br /> Local n /l If Referral,choose referral type(Fill one) <br /> Identifier: lLlt 02�Gt i79 (�p� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addfess DRI J21,13160i A'l F 0k A � <br /> l 3,2d/ <br /> Street <br /> n7�� Inspection Date <br /> I s' <br /> City State ZIP Code Time In Time Out <br /> Business Rept ,,[ Title �r 0 AM ? ®AM <br /> �0/V'+�'�fl FE J O PM [/E] J 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTEA ' lot, (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply)- <br /> O 0 Active ® Passenger ®Generator ®Outdoor <br /> GPS <br /> 'Latitude. . —I. I�I I I�O Q Closed Q Altered <br /> Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> 071-17-1 -1- T] <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> BusinessType (Fill all that apply) <br /> Q New Tire Dealer S Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 4D Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture .Q Shredder Q Other l I <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> W1 A HAULING AND M IFEST QUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance ea line <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 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 I CIWMB E forcement <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 In Compliance - No Violations <br /> Q Q 1 Other. § , <br /> Comments <br /> 1 � <br /> Inspection Form Included: Q � 9 <br /> Comments Included: Q - /2�►��G�����'/R-!tort ���-033 <br /> Business iep0's"Sinature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Incorrect: . XAhh PL E 1Z 3White CoYellow Copy'Operator Pink Copy LEA <br />