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07312040430 <br /> = 11¢ Waste Tire Survey & Inspection Report Inspection Report Number <br /> Stat o ofCalifo,ni, <br /> ■ <br /> Survey Form - Page 1 19 <br /> CIWMB 181(Naw 04104) <br /> California Integrated Waste Management Board 1 0 7 3 5 6 4 <br /> Part A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- -•� Z m Inspection Type (Fill.one) <br /> Site Suffix: f o T -s Q 18 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral;choose referral type(Fill one) <br /> Identifier, S Q CHP Q CIWMB 'Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address zil _ F/1o7LA_ <br /> IStreet /D.i7 S—�wrn�.tsv � I <br /> nspection Date <br /> City— �State�ZIP Code Time In Time IIOTut I� <br /> Business Rep Title 0 AM0 AM <br /> EE m®PM L� ®PM <br /> s v <br /> jt__ <br /> J Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) , j j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r• ' I SJ ®Active ®Passenger ®Generator Q Outdoor <br /> -t I O Q Closed Q Altered <br /> GPS Latitude I J• --J� Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - I JTI <br /> _-_� ( `f` _L I—L--� O Planned Q OTR O End-Use ®Container <br /> Business Type (Fill all that apply) JJJ <br /> ®New Tire Dealer ®Auto Repair Q Trucking Fleet Q 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 1 i <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 O PRC§42951-Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Co pliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / IE <br /> m <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Requ/red for NOV or FXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O O Other: §, <br /> Comments �^ p <br /> _ _ Ms�•f-1c�._a�^�f1t— [.4�; Z_C(cr_ (y!cl�.�- /Jy+-P_/_i+al�¢f-r� <br /> _��✓_t. .._tiGl�'L�J�r�-J IGEtt...ccf- Nt:./ r....r! ice_—��� v 1��73��'- D�� — <br /> yi�! — <br /> { <br /> Inspection Form Included:Q / <br /> Comments Included:Q X <br /> Bust ep'snatur Phone Number In.sp�ector's fS re 5�68Phone 6Nuzmb3er <br /> INSTRUCTIONS O C <br /> correct: E X A M P ,L 1 2 3 62081 <br /> ■ White py.CIW Yellow Copy:Operator Pink Copy.LFA ® ■ <br />