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--- -7 <br /> ■ 08080040002 <br /> eu <br /> Waste Tire Survey& Inspection Report Inspection.Report Number <br /> State of Califomia <br /> CIWMB181(New 04104) Survey. Form. -Page 1 1 5 - 10 7 9 10 4 <br /> Califomla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- flfl Inspection Type (Fill one) <br /> Site Suffix:. 2 O 1 Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 70Qq w ri CourT�-� Q CHP Q CIWMB Q Complaint Q Educational.Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> LKr_�s��an Lucas—I <br /> I '5-77? 5. Ere'nch Carne Rc)a� <br /> Street <br /> Inspection Date <br /> L_5:±0Gk o_h Cii4 152061 J <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title OAM O AM <br /> m m 0 PM [1] O PM <br /> Operational Status Tire Type Business Rote Storage Type <br /> `I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> 0i. <br /> Q Active Q Passenger Q Generator, Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> F <br /> Inactive Q TruckLongitude - I lO Q Planned Q OTRQ End-Use Q Container <br /> Business Type (Fill all that apply) ��11 1111 1111 <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 p Car Dealer Q Collection Q Crumb Rubber <br /> `•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 I 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 Q 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 In Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments i`�out��le 1f15�77�5��10 t Uroi-d 4k' _sce�N � ts <br /> wec2�enera�erlL--�Co—t�-1L13�n.L— <br /> ;ftCb all <br /> -t'� 1►'7 � ttieed� <br /> Inspection Form Included:Q <br /> Comments Included:r l LN <br /> Business.Rep's SignatureOrionslumber ector's Sq nat re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK.I Correct:0 Incorrect: [E XjAjjMjP1'L1E11 111,2131 ■ <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy.LEA L <br />