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Waste Tire S&— y & Inspection Repos* Inspection Report Number ■ <br />�i ■ State of California <br /> CIWM6181(New04/04) Survey Form - Page 1 - U f V <br /> California Integrated Waste Management Board - -- - <br /> Part A Survey <br /> BLUE OR BLACK INK PE <br /> Bustng s,Proffle <br /> inspection tails, <br /> TPID- `'] Inspection Type (Fill one) <br /> Site Suffix: 1 1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local LL If Referral,choose referral type(Fill one) <br /> Identifier: S C?�C` To a taw� C,o U n 1] 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> CA- _0_r_LVw9___j <br /> 10 —.1-------mcu:6!�Lt_ f__)� <br /> street <br /> Inspection Date � 5� E <br /> r., ( �Q <br /> ( _� " Time In Time Out f V <br /> ,, - s rile ZIP Cody L.1-] <br /> Business Re Title 0 AM 0 AM <br /> CC�r.k\c -vUr O PM •�,�. O 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)=i <br /> ® Active 0 Passenger ® Generator 0 Outdoor <br /> T— <br /> 10 <br /> 1 0 Closed 0 Altered <br /> Latitude <br /> GPS -� -- 0 Hauler 0 Indoor, <br /> 0 Inactive 0 Truck <br /> ,O <br /> Longitude - 0 Planned 0 OTR 0 End Use 0 Container <br /> �•— �� •mow _ � � - __ _ <br /> 0 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 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder (a Other CO�r.._n ..,.. M 1-�1IJq <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 'HAULING AND MANIFEST REQUIREMENTS <br /> O 0 § - Q Notice Of Violation Q Extension <br /> PRC 42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 /> 0 O -- --- - <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 f 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 /> 0 0 Other: § <br /> Comments01A 1i _� J- -���-Q�- Cit _r'tOrfA l�_6L&f <br /> � ... +� <br /> Inspection Form „Included. 0 <br /> I <br /> Comments Included: 0 _ - <br /> Business Rep's Signature Phone Number Inspector's Signature, Phone Number <br /> INSTRUCTIONS ON BACK Correct:* incorrect: \/ Tl TZ 3.n - 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> vv <br />