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Waste TireWWO& Inspection Re t110 1+0ection Report Number <br /> ■ State of California E ein - 1 ,. <br /> W7 <br /> CIWMB 181(New 04/04) �urVey Form - Page 1 I ,F E f _ • - � <br /> California Integrated Waste Management Board <br /> a <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- L'^L5L � / �. � � � ��LI <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 /> ('1 Y� �U <br /> Identifier: t QCT ldln C--O LA Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address J � 9j - L <br /> I-.�rk St 1 ct YJ ..� S�c�c� <br /> Stres7 ---- 1's -1 <br /> Inspection Date ©1 — c) H081 <br /> Cityi <br /> State 7 Coda Time In Time Out <br /> LL, 1 <br /> • �,. <br /> Business Rep Title -^ O AM Q AM <br /> 0 PM O PM I <br /> �. <br /> Tam CambC l <br /> —' -, Operational Status Tire Type Business Role Storage Type <br /> " Fill all that apply) Fill all that apply): <br /> (Fill one only) (Fill all that apply)', ( pp y) ( pp y)I <br /> The Count(Whole/PTE) Z <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> Latitude <br /> Q Hauler Q indoor <br /> FE Q Truck Ina <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 ENFORCEMENT STATUS <br /> VV AUAH LING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> 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 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 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 i ( , t J <br /> 4v1�T \ctQ �CU�t r��Q� sY2Y#t�C r (� 7tln1 -CeCx�� Q <br /> l : _'05-e�_fres S c <br /> Tom �_A?Qn V77�Ute5 O CA n l�t SM L,ASt <br /> ffi�N 1101 <br /> a` ..,t +r <br /> INN (000 <br /> Comments Included: Q <br /> Inspection Form Included Q <br /> Business Rep's Signature Phone Number/ Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X 1p V A 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA _ ■ <br />