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Waste Tire SL Of y & Inspection Repo^lnspection Report Number <br /> 62 State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I 1 - 1088288 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I I -7 - E01 <br /> Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local -t- �OUnl If Referral,choose referral type(Fill one) <br /> Identifier: 5c}� `-t C�n�{ t (fin l y 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name _ Inspected By Inspector <br /> for -T���ckt n q _ <br /> Physical Address 3 1 Kr Ishan L-UCUS <br /> I 305 F�t��-e Ave _ 211 <br /> Street <br /> C� OInspection Date <br /> Cq15203 <br /> I <br /> State ZIP Code Time In Time Out <br /> Business Rep Title ' <br /> W 0 I ,ti Q AM Q AM l 0PM QPM <br /> I Rt�`�'�1�r� viir [� Yr1n C{ Mr. r .. - �- <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 /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> o 1 0 Closed 0 Altered <br /> GPS Latitude m • 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck N/A <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that appIy7 - <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 <br /> M / M / 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 I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § -- - <br /> Comments <br /> J <br /> tZu�t3 o_A-'tc orcf on-�►}� Fcc-iIJu oll-on WGA -rjre- <br /> J <br /> C C)r"I 1. 0,0 C v i c.Q +re �O�t' o _ ` � , (A Y e P7o <br /> J <br /> - en re_-"ISAtYu. kA 2Ye. aVGi1a blP_ �or__yit� w n< <br /> Inspection Form Included: DI <br /> Comments Included: 0 <br /> Business Rep's Signature,_- Phone Number In ec or's S6n <br /> - -- . <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: XA�, E P A m E111273 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />