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-- V71312040563 <br /> ® . a <br /> Waste TirelSurvey & Inspection Report Inspection Report_Number . . <br /> StaMB18te of li(Now Survey Form - .Pagel _ I 2 - 1 .013290 <br /> ; <br /> CMlMB 181(New 04104) y <br /> California Integrated Waste Management BoardBLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection O 17 1 Q ^'� _ !, Inspection Type (Fill one) <br /> Site Suffix: p� v ® Routine Q Re-inspection Q Referral Q Observation <br /> Local. � If Referral,choose referral type(Fill one) <br /> Identifier: Lam- To CCI ` . Q CHP Q CIWMB Q Complaint Q Educational Visit, Q Other <br /> Business or Facility Name \ ` <br /> /\J Inspected By Inspector <br /> 41 g4IS g✓r� tnon �tre _ <br /> Address J 3 11011 ] j— <br /> Physical <br /> I t��W �r A � ►tie. P� • -- ��r�--- <br /> Street <br /> I r � n ^ I Inspection Date <br /> City ,#JV1 /lJ" If _State ZIP Code Time In Time Out <br /> Business Rep Title OAM O AM <br /> Ci awl C-s � m m O PM m 0 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) 1 I t � <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> �I O ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 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 I I <br /> Part B- Inspection of Waste Tire Dealer,.Generator, Hauler and End-Use Facility. ENFORCEMENT STATUS <br /> V A HAULING 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. C-ompliance 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 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1:Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXn <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 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 ® In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments IPC,.f j nSAEC t&" r r�Q 1t"� r 1 a_n <br /> U'� f P Vie. ty <br /> ►re Ilea{�5 � Knoh -Fire no loner �� ro 0,� l�ctS S`fDya <br /> P 9 p ' <br /> of acare.Ss, p'n_-tD_C. Ip-Ln Clo" (;aaa F . <br /> { <br /> Inspection Form Inctuded: Q <br /> Comments Included: Q <br /> -- 0501 y� to6 <br /> Business Rep's Signature Phone NumberI <br /> ktleilture_ <br /> Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X A M P L E 1113 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> I <br />