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. Waste Tire Su*y & inspection Reporto Inspection Report Number <br /> State of California <br /> $rnia CIWMB 181(New nage) Survey Form - Page 1 -.I 1 - 1086992 , <br /> California Integrated Waste Management Board J <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Prof[[es'' Inspection Details <br /> TPID- _1._. ✓ . ` / Inspection Type (Fill one) <br /> } Site Suffix: / ? / � - T Routine Q Re-inspection 0 Referral Q Observation <br /> Local ,f') If Referral,choose referral type(Fill one) <br /> Identifier: �(( <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ✓Gil ` Inspected By Inspector! ("; { , _�. <br /> Physical Address �— _ <br /> Street Inspection Date-1042 <br /> City State ZZ/—p Code.d Time In Time Out <br /> Business Rep Title r Q AM �70 AM <br /> 1 : <br /> l U <br /> ® PM LOTI ' C✓� � PM <br /> i <br /> �1' <br /> ,.- <br /> Operational Status t+he'Type Business Role S##�regeType +. <br /> The Count(Wr (Fill one only) (Fill all that apply)' (Fill all that apply) (Fil►all that apply) <br /> " MoIeIPT� _X �� �`�} , <br /> a uµ, <br /> Active @Passenger Generator d Outdoor ) ' <br /> �f <br /> 77-10 <br /> O 0 Closed Altered <br /> GPS Latitude { . . 0 Hauler 0 Indoor <br /> J 0 Inactive 0 Tr_uck� <br /> I <br /> Longitude 0 End-Use Q Container ', <br /> - 0 <br /> Planned O,OTR li <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> �.0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A !HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date ELI m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 ! 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities s <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> r--J - <br /> � �� ("✓ .i `.I ; CE _ ' lGi� _j �l l'�j ', i ttt. �)l l� "f / ` ( <br /> Inspection Form Inch ed: Q. � <br /> Comments .Included - ---- _- a <br /> Business Rep's <br /> Signature---- Phone Number Inspector's gnature Phone Number <br /> - —- --- <br /> X 62081 <br /> J„ <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: '`i ; � <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />