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■ = Fn, Waste Tire bU wey & Mspection Report Inspection Report Number <br /> State of California `� r-� <br /> CIWMB 181(New 04/04) L.1J�vaq Form « 'age 1 � typ��t�. - 10 {(p 9 9t A <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile <br /> Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: � .3 * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S n J 0 0, U (� �� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address Ron sj <br /> ebb � , �r�,mt�n► � e --- - - - <br /> C( <br /> Inspection Date <br /> � /� C s�oS <br /> Q�"j�k V n Time In Time Out <br /> Business Rep Title ^ AM <br /> Q AM <br /> ® PM S ® 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) <br /> Tire Count(Whole/PTE) 5 <br /> ®Active 0 Passenger ® Generator ® Outdoor <br /> 0 0 Closed 0 Altered <br /> GpS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive •Truck <br /> Longitude - 0 Planned ® OTR End-Use Container <br /> ® <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 /> •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 <br /> A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 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 m M 1 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 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 /> 0 0YRequirements - ._ -- ---- <br /> 14 CCR§18461 -Manifest System for Waste Tire End-Use Facilities i <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance No Violations <br /> 0 1 0 Other: § - — -- <br /> Comments <br /> Inspection Form Included: 0I ` <br /> �ry� f <br /> Comments Included: ® OAT'V / <br /> Bu iness Rep's Signature Phone Number Insp is Signatu Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ( J ?� A M (r 3 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Co y:LE <br />