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Waste Tire & Inspection Repa� spection Report Number <br /> ■ _ - _ ■ <br /> State of California I <br /> CIWMB 181(New 04/04) Survey Form - Page 1 ! I_ - <br /> California Integrated Waste Management Board 1 _ - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile tnspection Details <br /> TPID- �^ LL r/ Inspection Type (Fill one) <br /> Site Suffix. ( f I I,. 11. ( 1 Q Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: � � 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (- Inspected By Inspector <br /> , / <br /> Physical Address <br /> LL-1 - L <br /> Street Inspection Date <br /> city State Z/P Code Time In Time Out <br /> 0 AM 0 AM <br /> �� � 0PM � 0PM <br /> Business Rep Title <br /> - ��— 1— �— -�� Operational Status Tire Type ;j Business Role Storage Type <br /> The Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> s <br /> ® Active Q Passenger I Q Generator Q Outdoor <br /> .`0" <br /> Closed Altered <br /> Latitude Q Q Hauler Indoor <br /> GPS " Inactive Truck Q Q <br /> Longitude - 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 Q Other <br /> Part-13 - 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 T / FF / 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 Q In Compliance - No Violations <br /> Q Q Other: § --- ------- <br /> Comments /f< -i ( , <br /> l / c. (':' �,.t. . , l.• it tti ! , f` flr,rZ. ,k f/ <br /> - — <br /> l IJ'1 V --s r 1' .. _� I l: V.F✓li` l• 7 J J' t.:'! �f'/) {r'X _ <br /> l'; / `-/t L l( I l'' �`'l�t i �✓f �t /irlt�t+ (.:t'r of /y �1(r+�+� ��L/ �, � — h`; <br /> 7 <br /> r ) r' �� � l L ��: i(� C/t 1�r r fi l✓ i'_ �VC'"�/': <br /> Inspection Form Included: Q <br /> Comments Includad: -_ <br /> Q',Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X t X I A M; 112 31 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> t <br /> t: <br />