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Inspection Report Number <br /> Waste Tire Suey & Inspection Repor <br /> State of California 1 1 10 8 8 1 11 <br /> ` CIWM6181(New 04/04ISurvey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey_ - - - <br /> Business Profile Inspection Details <br /> _ --- — — — <br /> TPID- Inspection Type (Fill one) <br /> f Site Suffix. , L +✓ Routine 0 Re-inspection Q Referral Q Observation <br /> Local ,� If Referral,choose referral type(Fill one) <br /> Identifier: _.. '1'j JG<i t f^j cGVN ' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address - I / <br /> _t_.__ <br /> 2on- 714 <br /> _. <br /> Street Inspection Date r <br /> T�] <br /> 3�_----_ �tat ZIP Com Time TimellOu.t <br /> _ <br /> 0 PM <br /> cin" OM <br /> Q AM <br /> Business Rep Title _ - <br /> .] <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Pili all that apply), <br /> y, Q Active Q Passenger Q Generator Q Outdoor <br /> O <br /> Q Closed Q Altered <br /> GpSLatitude I 9�^ Q Hauler Q Indoor <br /> 1 V ___ � Inactive Q Truck <br /> Longitude - I FT� F7F_7- O Q Planned Q OTR Q End-Use Q Container <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 Q Agriculture Q Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFORCEMENT STATUS - <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 100 <br /> 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 114 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 114 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 1 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> I .Q <br /> 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement <br /> Q Q 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 /> Q Q y q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments Q 41 fj r�/�t� . <br /> 1> - <br /> - 11 �� <br /> LJcx ((Z a� �� /i �—• i f C.�6�-«�tcM ct.; <br /> i J c <br /> t� n 'v�"�rtr✓r N.+a: a>°T` i, '" ,,r ;,,,,r i y r.!y ,' ro , ✓ , ?" <br /> Inspe ori Forts Included <br /> ! yar " tt1W r i a �ne �r tnBtUlea�. Phone Number <br /> - -- -- � - -- 62081 <br /> CreCt: InCOrre `�" <br /> INSTRUCTIONS ON BACK Co • � � _ .. <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> tri <br />