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Waste Tire y & Inspection Rep Inspection Report Number <br /> 'a@7 State of California <br /> CIWMB 181(NewSurvey Form - Page 1 I 1 - 1141342 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i r L Inspection Type (Fill one) <br /> Site Suffix: ' 7 I I I� I Q t ® Routine Q Re-inspection Q Referral Q Observation <br /> Local \ �r✓ I �� If Referral,choose referral type(Fill one) <br /> Identifier. 1r' ,GO u ii 1 �l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> �--- Inspected By Inspector <br /> �j <br /> Physical Address � 1cl <br /> I 71 � <br /> I I � ',�y,} Aid) /hl�,_�L <br /> ....... .._.._... <br /> i..c.. --.. �h.c. ...���._ -- — -....--- - -- <br /> btres.,t <br /> Inspection Date <br /> k—ic—c ��'� 175 LG 5 <br /> C`;v StFje Zip Cf)�'p Time In Time Out <br /> Business Rep Title <br /> j 0 AM i <br /> _ � 2 O AM <br /> O PM0 PM <br /> 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 /> Tire Count(Whole/PTE) <br /> IS Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude i 1 D Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> r- —.,_.._.............._.... _. ...... <br /> _................._t...._...._...._ _.... 00 Inactive 0 Truck <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fitt all thaf 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 B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> —__ __—._____ 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 7 / 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 <br /> Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments � i'C; 1 /} �� [� i J r - �1tG � t� yi// 1� <br /> Inspection Form Included: Q' <br /> Comments Included: Q <br /> Business Rep's Si ure Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Corr ct: correct: X ;x i A �P tJR <br /> 62081 <br /> White Copy: IWM Yellow Copy:Operator Pink Copy:LEA <br />