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016050063 <br /> Waste Tire SuAy & Inspection.Repo Inspection Report Number <br /> C1 <br /> State of California ClWMB181(Now 04/04) SurVe Form -Page 1 I1 - 1144033 <br /> Ii¢Y /uy <br /> California Integrated Waste Management Board y J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile. Inspection Details <br /> TPID- it� <br /> .© ( Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1� �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I �Gl�4e� Cil c� � I _ / <br /> Physical Address L-41"Q_m►n b _ <br /> L_7!��rl1 _ff--r F <br /> Street MIL, l a l a o <br /> Inspection Date <br /> I Ua'l�cc� CA 8533(:;,1 <br /> City State ZIP Corte Time In Time Out <br /> Business Rep Title Q AM ' L 0 AM <br /> PM PM <br /> — . Operational Status Tire Type Business Role Storage Type <br /> Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> --� I---' ®Closed Q Altered <br /> GPS Latitude •i I_ ; 1 f /V/,4. Q Hauler 0-Indoor. . <br /> Q Inactive Q Truck <br /> Longitude Q Planned Q OTR Q End-Use Q Container. <br /> Business Type. (Fill all that 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. E.NF�ORGEMEN;TAUS <br /> V- A HAULING+AND MANIF.ESITREQU REMENTS Q NoticeOf Violation. Q Extension c <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 <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 fvOV or FJCT) <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 0 - 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance -.No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> �3 <br /> Comments Included: ® — - — — - kilatureBusin eps a ;: ,Phone Number. - t ? -Phone.Number- <br /> 62081 <br /> INSTRUCTIONS ON BACK Cor ec " ncorcect: EIx AIMI P L11-12F31 <br /> " - White Copy: IW Yellow Copy:Operator Pink Copy:LEA <br />