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Waste Tire Su y & Inspection Repo Inspection Report Number <br /> Hill <br /> of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 I 1 - 1088004 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- /^ ^^ll !! Inspection Type (Fill one) <br /> Site Suffix: ' � Z b 7 Is _ v�l ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �SQfI 7C?QCIUI n C OUf��� _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> ` Business or Facility Name _ <br /> Inspected By Inspector <br /> ABC- F <br /> Physical Address �� Q <br /> Y 1 3 _ LKY tom. i Gn Lu C,a �} <br /> L --._ LOEB]Street p / ) -, / <br /> Ins ection Date <br /> L__`L_)t0 C_�,Aon clh� 915 q5 I LC L7City State ZIP Code <br /> Time In --_ [._ Time ut � __ <br /> Business Rep Title L L.- <br /> O AM 1 f O AM <br /> 0 PM 0 PM <br /> J Operational Status Tire Type '� Business Role Storage Type� <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude , Q Hauler Indoor <br /> Q Inactive Q Truck <br /> Longitude Q Planned Q OTR Q End Use !� Container <br /> Business Type (Fill al!that apply) <br /> Q New Tire Dealer Q Autp 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 Q Other <br /> Part B ENFORCEMENT STATUS <br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I_ _ <br /> A 'HAULING AND MANIFEST REQUIREMENTS <br /> Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> OIO PRC§42951 <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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive p <br /> 14 CCR 18460.2-Manifest SyLogs for 3 years <br /> stem S sm Requ reme tsfor Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> ;. � Q § <br /> Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q 14 CCR§ 18462-ManiQ In Compliance - No Violations <br /> Other: — <br /> Comments Root i r1Q 1�S�1Q-cr'�\Q.1'��_�`T U! _1 S ���_�t� w i n ck <br /> -� treP> -'_ u7 - -� f i-��tr� >✓ erg_f��►� } <br /> anA C s_t w F)-e rn JE- <br /> } o '41G 1 S car_ CA f_e U _.0 CJ_)C kt(� 1C cYi <br /> I. r °�"'M .v✓' / . ,: w N .P; r rN. �, r . �� r l��f '� � M r,:n �" ,,� h r ¢; r�, 2 t%w� i x aw � ¢ �• M GF <br /> Inspection Forrn�Included. { <br /> ,6 <br /> Comments Included: — <br /> Q,Bus} ess Rep' Signature Phone Number In for s SNgnature Phone Number <br /> I�� V ` 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X "v . <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> L --- <br />