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® Waste Tire Sy & Inspection ReporInspectionReport Number ■ <br /> California State California r era r� .� <br /> r <br /> .... `, <br /> CIWMBB 181(New 04104) SUCVe Form - Page 1 t <br /> Integrated Waste Management Board y <br /> Part Ac <br /> BLUE OR BLACK INK PEN <br /> _ _. _ <br /> ess ProfileInspection Details <br /> TPID- I ( -� ! Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local — - - If Referral,choose referral type(Fill one) <br /> Identifier: �� tj Q CHP Q CIWMB Q Complaint Q Educational Visit Q.Other <br /> Busine s or.Facility Name <br /> f -^� Inspected By Inspector j <br /> Physical Address <br /> Street <br /> l�..�- Inspection Date � Q L� � 12 " <br /> �•r-7 p � �/ J��� <br /> I 11ZA C_ Slate ZIP c7a(doe� Time In I Time Out <br /> _ -_ — - <br /> Business Rep Title OLL] AM 1 O AM: [T 0 PM 0 <br /> PM <br /> - Operational Status Tire Type 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 /> r Q Active Q Passenger Q Generator Q Outdoor <br /> „t. <br /> __ <br /> __ 7__ __ O Q Closed Q Altered <br /> GPS Latitude <br /> E <br /> � Q Hauler Q Indoor <br /> Q Inactive Q Truck <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 /> - - _ 7ENFORCEMENT STATUS <br /> Part A IHAUL NG AND MANIFEST REQUIREMENTStor, Hauler and End-Use Facility �0 Notice of violation Q Extension <br /> O 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 <br /> mmm0 /Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> O O --- -- - <br /> 14 CCR.§18459.3-Retention of Comprehensive Trip Logs for 3 years li <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 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 <br /> Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments -? / <br /> 4 <br /> t <br /> 'T(F�f <br /> Inspection Form Included: Q', <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X s E, i A M <br /> ." P I L 62081 L i �` <br /> ® White Copy:CIWMB Yellow Copy:Operator ; Pink Copy:LEA- ■ <br /> i <br />