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Waste Tire Sd" & Inspection RepoApspection Report Number ■ <br /> State of California <br /> CW <br /> MB 181(Newte 04104) Survey Form - Page 1 Il - 1088029 <br /> California Integrated WasManagement Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Inspection Details <br /> Business Profile <br /> Site -Suffix -7 ���� Inspection Type (Fill one) <br /> TPID i <br /> F0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> ZT-0 6,q Q'i n CounA If Referral,choose referral type(Fill one <br /> Local <br /> Identifier: F 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> @usiness or Facility Name <br /> Inspected ByInspector <br /> IL <br /> Physical Addres.4 J-Loi-1 I' i_-1 r V5tiqri L-LAcas __j <br /> Street CA 95ZOV Inspection Date ,=10 Fna <br /> City State ZIP Cdde Time,In Time Out <br /> Business Rep Title 0 AM OAM <br /> 0 PM 0 PM <br /> Operational <br /> erational Status Tire Type Business Role Storage Type <br /> "T <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 1 1: 3 1 <br /> Active 0 Passenger- C) Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> Latitude <br /> GPS 0 Hauler 0 Indoor <br /> 0 0 inactive 0 Truck <br /> Longitude 0 Planned 0 OTR 1 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 1@ New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> # Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> M / FF / T <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 in Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> r0_rrr-.--ed -4v_43110 LA.)CLS 110+1?o <br /> A00TOX. St Lo o,�*e,/,k5e(A dn-5� e , F&"k� ths-es—N1 UTK. 'Compary <br /> j <br /> Lakilr% -T k re UjezA- g FCCQ\C% Mm SQ\ &r 0040 IS,erl Y*,e rt avQ1. <br /> CTL mr,(-Ae,,)4-- i'e v,)42cA . NJ(D s4\0�ok�car)� or q <br /> rec J_ <br /> Inspection Form Included: 0: <br /> f fl <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number in ec or's Signaturl( Phone Number <br /> Xi <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: 62081■ X V <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />