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Waste Tire Surly & Inspection ReporInspection Report Number ■ <br /> ® <br /> WUState of California11 — 10VVL �.dSurvey Form - Page 1 <br /> zi CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> -- <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 I� �aZ L/ `�� Routine Q Re-inspection Q Referral Q Observation <br /> Local ---��� - --��— Y If Referral,choose referral type(Fill one) <br /> C%n To�\� ..,t n L U.,I r�;A- .a <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or F ~ — <br /> acility Name Inspected By Inspector <br /> - --..-----t_ h o r e n T r u.4 <br /> Physical Address T - FT11U1 t`,f i`tet 1 Girl L (A C n:, j <br /> Street ---- <br /> Inspection Date Z <br /> - --- — Time In Time Out <br /> Business Rep Title <br /> State ZIP Code ... __. 0 AM . l�- 0 AM <br /> 1 f` <br /> O PM --_ O PM <br /> Operational <br /> I Status eType <br /> Business <br /> ole Storage <br /> Tae <br /> (Fill only) (Fill apply) ( that apply) apply) <br /> ® Active Q Passenger <br /> (7) Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude � , Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Lon 9Rude Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 FENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> Q I Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m m m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q14 CCR 14 CCR§18459.3-Retention of Comprehensive Trip Trip <br /> sgfor 3 years -" "-- - - - <br /> 18459.2.1 -Submittal of Comprehensive Tri Logs within 90 days <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q014 CCR 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q § Y q � In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments 1, c <br /> ' .. E <br /> �'��l "P��—��C.�1�Y1 �( U (tv",5�(-' \_ I � =� ��'-`-�t! 1 ...�' � ' <br /> L�1c:ta Ttf Co Snc . �rf ilr cJ►C� � Z_t a� �T rn�n +T . '�_ Gvot�_•.,��'. <br /> TC.'ry\r2.:,�" ' "y_C� 'c�T `---- �, r�r c_ Y OIr2Q•:, con(,e_r-n . -. <br /> Inspection ri Form Includes.+ `,� �'" ✓r / <br /> r qq <br /> '"' ,�s drM.•t ,,.., a ..,. � k� . �J . 4'd '� �' <br /> Comments Included <br /> BusinessRep's signatme is Signature,^ -- —Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:,* Incorrect: <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />