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' <br /> ;111 Waste Tire Sy & Inspection Repo'Inspection Report Number <br /> ■ <br /> St1088420 <br /> ate of California i ® ® O <br /> CIWMB 181(New 04/04) Survey Form - Page 1 _l <br /> California Integrated Waste Management Board J - - <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile ;Inspection Details <br /> TPID- n- L r- Inspection Type (Fill one) <br /> Site Suffix: f 0 l 1 �(1� � G l � Routine Q Re inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: 1 ..` \`v l �L Lti 1. ( �ll Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ---t— Inspected By Inspector <br /> Physical Address <br /> ---- <br /> Street <br /> q. Inspection Date <br /> State z1 , Time In Time Out <br /> City c� -- P Code _. <br /> _ E � IBus 3s Rep Title AM AM <br /> ® PM17- PM <br /> - <br /> - Operational Statusslireype Business Role <br /> Tire COUnt� �10�e� T. 7 (Fill one only) (Pili all that apply)'' (Fill all that apply) <br /> , ® Active Passenger" ® Generator <br /> �— <br /> Q Closed Q Altered <br /> GPS Latitude , E'10 <br /> �' Q Hauler <br /> Q Inactive Q Truck <br /> Longitude Q Planned 01 OTR Q End Use Q Gontalnef <br /> Business Type (Fill all that am <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 ''I A HAULING AND MANIFEST REQUIREMENTS 10 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 <br /> M / 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 O - - - - ----- - <br /> 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 @ In Compliance - No Violations <br /> Q 0 (Other: § - -- <br /> Comments 1, 41 1` <br /> 4 _ <br /> boo r«, "0"6-, 'sJ,''nn .P,k. �,a� Fdv r�. � w> r'",.r �a p r ^o r%/h:'%F i,"�o sw + ✓ / Sid .^✓^S.,qaY.b s9 b 9 ;l;p' l. <br /> s ri <br /> r <br /> Inspection Form Included. Q <br /> Comments Included: I – -- <br /> Business Rep's Signa/ure Phone Number Inspector's Signature Phone Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: �/ E X M�P� l..I E i ill <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />