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Waste Tire Su & Inspection Report Inspection Repott Number <br /> State of California s <br /> CIWMB181(New 04/04) Survey Form - Page 1 3 � - 1 0 7 ? 7 <br /> California Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business ProfileI Inspection Details <br />} TPID- Ask- <br /> Inspection Type (Fill one) <br /> Site Suffix: I - L—L Q Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: Lk I b /'t t G UN Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected By Inspector <br /> Physical Address I . ! I `A <br /> L3b <br /> X21 GlQ-1fC77 <br /> Street p� �1 <br /> Inspection Date <br /> _5—) O ckT Jv-� 5-2021 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title I I - O AM AM <br /> W <br /> ��Ne� 0PM 0 P <br /> - � <br /> Operational Status'T Type Business Role Storage Type <br /> The Count(Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> v ® Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered I' <br /> GPS Latitude - I Q Hauler Q Indoor <br /> C Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply). . <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> C 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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m m <br /> Q 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 /> Q O <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O in Compliance - No Violations <br /> Q Q Other: § <br /> Comments - <br /> ��t -VAT I NJ t11' -0r CTr i-W Oft 711.- ��- c< �►t-I�--��t CUJ�IC�IQ <br /> c <br /> IN fir' c Ltrw� r J 1 USA Tri, +: F( _ <br /> rI <br /> e-� �C�L_�� > e A I <br /> Tri = tj&C_ 11td .�. �C 'F�� "'T��} y'-„ �. �If%/� �C: Com►, t bl5 C ( �,1 N <br /> Inspection Form Included: Q <br /> Comments Included: Q _ _ - _ __ -z�•_ _ . _ <br /> Business Rep's Signature Phone Number Inspector's ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X V )( A ddI F Li 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />