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Waste Tire Sur y & Inspection Report nspection Report Number M <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 Il - 1143675 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: �� 7 6 ® Routine Q Re-inspection O Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. t� x'?,� L� O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name /z,p,,..7.r Inspected By Inspector <br /> -+G�-Gu'/z� LC2�ec•L f�'t�� E''��f f-��c:t�� LsHYY C, <br /> Physical Address f - / / J l�l3/iU'>/7/i4✓f) <br /> 9.5aL�1 Inspection Date � (j <br /> Time In Time Out <br /> Business Rep Title n _3 0 * 1M <br /> i AM <br /> LLlcu..tc�el- VJ ��7� o PM <br /> - - (/ --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r © ® Active 0 Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - Q Planned Q OTR ® End-Use ® Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 0 Retreader Q Dismantler O Tire Derived Fuel � <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station O Hauler Q Agriculture Q Shredder 0 Other �- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> '1/ A HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953 Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 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 /> 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 Q Referred/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 Generators ® In Compliance - No Violations <br /> O O Other: § '/D <br /> Comments -Ci'7..� / r!� lf�iz 'Z�[�f l tzuvCc2 ��e{u��3.� �� Gc •-� <br /> - <br /> Inspection Form Included: Q'I <br /> Comments Included: - - - - - - -- - - � <br /> siness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS BACK [Correct:* Incorrect X1 � lle XIA MJPJ �!E 1112131 62os1 <br /> ■ - --- - �,� ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />