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Waste Tire S&y & Inspection Repo Inspection Report Number <br /> State of Californiat —+ --_ <br /> CIWMB 181(New 04/04) ( <br /> California Integrated Waste Management Board Survey Form - Page 1 = -i <br /> BLUE OR BLACK INK PEN <br /> Part A- SurveyBusiness Profile_ - =- - -inspection Details -- - -- - - -- - <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: O 12� 2--ie_�) Lo 1 O Routine O Re-inspection O Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - ,!1'-) -Tocq n Count O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address l�r�S ,1: 10 1_1A 0_4 S <br /> �>l e r,-)o <br /> Street Inspection Date <br /> I t�lcrr��eCcX C.A !33�i V <br /> CHV State ZIP Code Time In Time Out <br /> Business Rep Title ��O AM O AM <br /> 0 P 0 P <br /> - <br /> Operational Status Tire Type Business Role Storage Type <br /> `fire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active O Passenger O Generator O Outdoor <br /> Latitude <br /> . D O Closed O Altered <br /> GPS O Hauler O Indoor <br /> O O Inactive O Truck <br /> Longitude - O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber ` <br /> O Service Station O Hauler O Agriculture O Shredder ® Other FQr f.l �_.. ..5er� 4 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> �olt�.x� r1(1'�'P�1 — u�t.P�, - t 001i <br /> T1c <br /> Dom"- ars Nto V1-4I - cohGern _off. <br /> Inspection Form Included: <br /> Comments Included: O <br /> 1 Business Rep's Signature Phone Number Igspector s Signatuf8 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X l ft hl, P I 123 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />