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VS252��C55Q <br /> Waste Tire Survey & Inspection. Report eee_ <br /> Inspection Report Number <br /> LE sIM tat.°gall'ern.. Survey Form - Page 1 1 7 - 1 0 7 9 3 1 2 <br /> CIWMB 181(New 04/04) <br /> Cal ltorn Integrated Waste.Management Board <br /> Part A-Su= . BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O Inspection Type (Fill one) <br /> Site Suffix: 7 0 Routine Q Re-Inspection. Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q?�itC[r Q CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br /> Bus_ineess or Facility Name _ Inspected By Inspector <br /> ZS <br /> Physical Address ,/ 3 9 fJ / I S'Lj� �✓ <br /> Street �Q /� <br /> I �7� v/ /6�D I Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title AMAM <br /> ERIOPM Q 0 O PM <br /> Operational Status Tire Type Business Role Storage Type. . <br /> Tire Count(Whole/PTE) ! D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> - 40 Active Q Passenger 0 Generator. Q Outdoor <br /> _ Q Closed Q Altered d <br /> GPSLatitude H -L <br /> Q Hauler Q Indoor <br /> O Q Inactive le Truck <br /> Longitude 1-171.7-1-m - <br /> Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car healer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of violation Q Extension <br /> 0 O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement <br /> O Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> Q Q Other: § ,,0 <br /> Comments � // .//r_ /J �J "T a"'I � <br /> -�QPa°Ll- {�(//d t C�iL1e.F/G�� %ISG C� / ✓'G L�/� <br /> - jy . e TL 's �.�✓P.Q/ �� i�'�uy�. � v,°o->aaxS o�- <br /> inspection Form Included:Q rk� q <br /> Comments Included:Q <br /> Business Rep's gig re Phone Number Inspector's Signature- Phone Number <br /> INSTRUCTIONS ON BACK Corre t: Incorreet: [ X a M'P I62081 <br /> L 1 Z 3 <br /> . White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />