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=s= Wast ire Sure & Inspection Report �pection Report Number <br /> L <br /> 111. <br /> 8tate of WMB11(N la Survey Form - Page 1 1 5 - 10 7 9 4 4 2 <br /> CIWMB 181(Ne� 0'04) <br /> California Integrated Waste gement Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: y Q ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: CawAk r O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name S'rQtr_ Inspected By Inspector <br /> Physical Add srl� s - 0 A" &Fmri,-c . <br /> 33-�- z , <br /> Inspection Date 6 3 Z 7 0 <br /> ,per ��36� <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ' <br /> 70 PM QPM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ® Active 0 Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - ® OTR O End-Use Q Container <br /> Q Planned <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 O Agriculture Q Shredder ® Other p C�riffrL[-G <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -- <br /> VJ <br /> A ;HAULING AND MANIFEST REQUIREMENTS <br /> _. _ _-. -— -_—_--- --- ----- - --- ---- Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Tri Logss within 90 days --.. (-R-e-quire-d-for NOV or EXT) <br /> . - - - <br /> --. <br /> Q O 14 CCR 18459.3-Retention of Comprehensive Trip Logs for 3years <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 /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O In Compliance - No Violations <br /> O O Other: <br /> Comments <br /> -- <br /> �� He- 1L/►t�et`�j <br /> Ins ection p Form Included: 0 <br /> X - �In`spector's <br /> Comments Included: Q. <br /> Business Rep's Signature Phone Number Sign re - Phone Number <br /> INSTRUCTIONS ON BACK AjM P E1 1 Z 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />