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Waste Tire SuMey & Inspection Repor Inspection Report Number <br /> $fig' State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 1 - 1127641 <br /> California Integrated Waste Management Board - <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> i' <br /> Inspection Details <br /> -TPID- i € -' Inspection Type (Fill one) <br /> Site Suffix: J L <br /> j Referral Observation <br /> Q Routine Q Re Inspection Q Refe al Q <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> 'I- Q CNP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name f i Inspected By Inspector <br /> Physical Address <br /> r r <br /> r/'ee= ­7-71 <br /> -�� Inspection Date <br /> Business Re T..._- � _ <br /> r:.., <br /> State Zip Cade Time In Time Out <br /> Rep Title O A M i O AM <br /> �-' ... <br /> [� � Jit -'" <br /> 1I/1 _vl>/ -� -2 Cf. O PM ' l� � z' O PM <br /> ._...__ Operational Status Tire Type Business Role Storage Type <br /> �) (Fill one only) (Fill all that apply) (Fill all that apply) (f=ill all that apply) <br /> Ttre Counf�WI-toBeIFTE} i ! _ , <br /> Active Q Passenger Q Generator 0 outdoor <br /> m .W '1 <br /> 0 Q Closed Q Altered <br /> GPS Latitude _�I _.__ 1 � <br /> -----------�_._. <br /> 0 Q Inactive Q Truck <br /> Hauler J indoor <br /> Longitude - Q End-Use Q Container <br /> Q Planned a (J1 R <br /> Business Type (Fill alit apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 Q 1— ---- - --- -- Q Notice Of Violation Q Extension <br /> 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 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 _P'' <br /> Q Q i 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Other: § _ -- <br /> Comments <br /> kt1 <br /> ,I'I r_yt tV {P s .f✓� L -i l �'C �.i _fes- .- 1'(V 1 4. _ - !� <br /> a 4�tLb <br /> IV-V'1fie. � lre s,,--V; cr�'.-(�-/ _ - irey, 3 �/,otx 3rd J i1,r- 3� hi�i 1 0,0,5 67.05 �I�. 'P,0 <br /> Inspection Form Included: 0 <br /> Camarents Included; Q , <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:6 Incorrect: X �' A0, ! t <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />