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Waste Tire Sey & Inspection Repor Inspection Report Number <br /> h. <br /> ' State of California i : ■ <br /> A"iCIWMB 181(New 04104) <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> _ ,. .; <br /> 13ustnes F�rofilea(I° ( `. Lnspecfilan Details <br /> TPID- IL <br /> Inspection Type (Fill one) <br /> Site Suffix: L (p" 3 �j - � Routine Q Re-inspection 0 Referral 0 Observation <br /> Local _ If Referral,choose referral,type(Fill one) <br /> Identifier: Ea� SG> q a\ n C.��r c.��� 0 CHP 0 CIWMB Q Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address _ - _. <br /> t <br /> SirPet � `�; �� <br /> Inspection Date191- - <br /> �` � Q ' q / LOL8] <br /> City �o�k�ca`� �-�1� . �� Z ���� Time In Time Out �� <br /> Cilli .stat+, r'1F?Code _ <br /> Business Rep Title Q AM _ Q AM <br /> CSU ==���� O PM Q PM <br /> O Operational Status Tire Type Business p yp � ess R Role Storage Type <br /> d (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger Q Generator 0 Outdoor <br /> (� 0 0 Closed 0 Altered <br /> GPS Latitude 0 ( � 0 Hauler 0 indoor <br /> i C 0 0 Inactive 0 Truck <br /> Longitude - 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 0 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 j <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 ',I 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 IE / m Ell <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 0 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 /> I <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 <br /> In Compliance - No Violations <br /> 0 0 Other: § -- -- <br /> Comments <br /> sr r � --�-h�° � � _`i-��1Q w li n <br /> J <br /> -�- tJ1 y 771 roc _ <br /> - _ r�r Uroa <br /> T- Y' <br /> Inspection Form In l ed � " a ��" <br /> C lA,d t d f n ^4- <br /> Comments,Included. = f <br /> Business Reps Signature Phone;Number Ins c or's Slgn ture,. Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: . l A_ JI ' _ 62os1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ " <br />