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Inspection Report Number <br /> Waste Tire SL ay & Inspection Repor , <br /> [79� State of California <br /> CIW <br /> MB 181(New 04/04) I - <br /> California Integrated Waste Management Board 9 <br /> Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> spection Details <br /> TPID- q Inspection Type(Fill one) <br /> Site Suffix: I�jr� l `— I - ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type Fill one) <br /> Identifier: S-tn 7oItin �O " T O CHP O CIWMB0 Complaint O Educational Visit <br /> Other <br /> Business or Facility Name <br /> Us Inspected By Inspector <br /> Physical Address t k ToT, C', <br /> 1C�, -Z`� ,r - <br /> Street <br /> Inspection Date <br /> Lkt ,�;� LA iSZUG I (( V <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> rrcjy 5�0 r j7I-V is n • Q PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) <br /> (Fill all that apply) (Fill all that apply) <br /> Tire Count Vllhole/PT ® Active Q Passenger <br /> Q Generator Q outdoor <br /> GPs Latitude <br /> O Q Closed Q Altered <br /> m . <br /> Q Hauler Q Indoor <br /> ,p Q Inactive Q Truck ✓y <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <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 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. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / 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/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 /> Q Q Other: §. <br /> Comments <br /> C;t+a M�,�-�ac Ttitr �c,r_ crrnt �t1�A �01 .-Oo-A -tire removil C _TLL � J <br /> ,Fy1-T yO L-In&1A C.N , )l'AJ t - n r V 1 .J1.)t q—qon regj lct�• <br /> Inspection Form Included: <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inpector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X EXr�;, I r'' L E a l a'i 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />