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Waste Tire ftey & Inspection Repo[L Inspection Report Number ■ <br /> -117 State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 Il - 1143505 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile i Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J ,� Ll�^ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> fi:j4 me.rcukf� 3 g - s(o��b <br /> Physical Address ( O 1 Qen <br /> 1 A 1cb:)40 Inspection Date a 1 r7 0 <br /> Time In a Time Out v <br /> Business Rep Title n r 0 AM0 AM <br /> 0 PM O PM <br /> --- - -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 9 Closed 0 Altered <br /> Latitude N N <br /> N] A 0 Indoor <br /> GPS <br /> O 0 Inactive 0 Truck 0 Hauler�A <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body ® 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 /> M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 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 In Compliance - No Violations <br /> 010 Other: § <br /> Commentstitin, s�11 D <br /> t.lWe1j � Ale- br S X)Jks n( <br /> --- �. �v�c•�� <br /> Ame-A- -flo c, Fck(%�4 "sin ir1 s <br /> Inspection Form Included: 0; Lam, 1,� ^►rl <br /> Comments Included: 0! <br /> Business Rep's Signature Phone Number Inspe is Si nature _ Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: i E X ,� M f 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop : <br />