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09168.(350(_)1.2 <br /> Waste Tire SL ey & Inspection Repor Inspection Report Number <br /> State of California T 1 <br /> �rll CIWMB 181(New 04/04) Survey Form rm - Page 1 i +_+ - 1088485 <br /> California Integrated Waste Management Board g <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I , a I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n 4n (0 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> Physical Address Ll 1 <br /> Street n� <br /> A �� Inspection Date � ` I �a <br /> 140__c . _o_n _C _-- 1 LV <br /> ffi/,1 Sia. ZU-1 Code Time In _ _Time_ Out <br /> Business Rep Title I r 0 AM j i . O AM <br /> t O a t - --'-- J • ---- I O PM L-` - -� - a PM <br /> Operational Status Tire Type Business Role Storage Type <br /> •Tire Count'(WholelPTE) � (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' <br /> f 1 9 Active * Passenger • Generator S Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> _. O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer Q Auto Repair Q Trucking Fleet p Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 L- <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 Notice ti)f 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 <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 S In C-ompliance - No Violations <br /> Q 1 Q Other: § <br /> Comments �o ►i`�_���. - n- - —�--lS_ �- - - - -v�.t�l�l 5►-1CZA ' <br /> 4-C,:1 'F�a`' _ uses Pad,�1 �;c_�s mt- A <br /> Inspection Form Included: Q -� ( ] Q y Q �]R <br /> Comments Included: Ai t—{-u1L.¢S ` - l.i y6�Zf' _ _ _�' -" <br /> Business Re 's Si iture Phone Number I e rs Si nature �,Fhone Number <br /> P 9 P 9 <br /> INSTRUCTIONS ON BACK C rrect-, Incorrect: Ah X A P 62081 L E fl 2 3 <br /> White Cop -CI Yellow Copy.Operator Pink Copy.LEA <br />