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Waste Tire Si & Inspection Re spection Report Number <br /> 4 ® W <br /> i3,"C:^� State of California 1 - 1088005 <br /> p ,.w. ■ <br /> AM CIWMB 181(New04/04) Survey Form - Page 1 I <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile j Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 73 0 I ' ( �1 j J } Q�� <br /> L... ® Routine O Re-inspection O Referral O Observation <br /> Local � CO UT„� If Referral,choose referral type(Fill one) <br /> Identifier: 49w rt , O CHP O CIWMB O Complaint O Educational Visit O Other <br /> S Q!1 70 <br /> Business or Facility Name <br /> Inspected By Inspector <br /> r- <br /> y �ca.�e �-- te <br /> _.��.�n__._..� +r _ ) LSTJ <br /> Nwsical Address_ - - - ` Q <br /> ��� / Fi4l / �_�, <br /> Inspection Date <br /> L 5 �dc�oh C 6_ 95-05;; Time In Time Out <br /> r State ZIP Code E—E-1 <br /> Bus ss Rep Title i 10 AM 0 AM <br /> LIQ . OPM 1 0 PM <br /> _C.C1Se,t— G��QY1S �.Q-u1�1_ -L—.. � - — - <br /> Operational Status, Tire yT pe Business Role Storage Type <br /> (Fill one only) (Flll�all that apply) (Fill all that apply) (Fill all that apply)! <br /> 0 Active O Passengerta: ® Generator O Outdoor <br /> -�O O Closed 0 Altered <br /> GPS Latitude . <br /> I O Hauler O Indoor <br /> O O Inactive + TWO <br /> Longitude O Planned -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 /> ® Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> 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 / 1:1 / ELI <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O 0 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 I 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 Generatorsla In Compliance - No Violations <br /> O 0 I Other: § --- <br /> Comments <br /> Rom► ms 6 ion ,.e.r S ornv_ed -t6t, dc�e 4 -fhve SoIlow,r)? k Q __ noec). <br /> __F�cil►'rJ us�,s Tri ` C T_I� e�4 �1►n Scar_, � e .re rem -v�_�krp�r Y . <br /> Inspection Form Included O <br /> Comments Included - ✓t ,1. :; -- �-- -- 1 7 <br /> - Business Rep's Signature Phone Number Ig "pectoi s Signatur Phone Number <br /> 62081 <br /> ■ INSTRUCTIONS ON BACK Correct:® Incorrect: 1-m- ,geo, I_ 1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br />