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spection Report Number <br /> ® Waste Tire Su / & Inspection Report p <br /> State of California 11 - 1088399 <br /> CIWMB181(New 04/04) SurveyForm - Page 1 <br /> California Integrated Waste Management Board J - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> _ - <br /> TPID- l Inspection Type (Fill one) <br /> Site Suffix (0 Routine Q Re-inspection Q Referral Q Observation <br /> Local f'i If Referral,choose referral type(Fill one) <br /> Identifier: '( i 1 ��. <br /> �C-4 -�L(Yl t..-.r,��.:2Ut. � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> � / }. • Inspected By Inspector <br /> Physical Address F/ <br /> I <br /> JI .F-1/ <br /> Street ;_ . � <br /> Inspection Date <br /> 1 <br /> City State ZIP Code Time In - 0Time Out <br /> Business Rep TitleAM O AM <br /> J_—P C10 C 0 PM <br /> ' <br /> L—. 6f.1s, i•1"- a �� _ �t i <br /> g - <Operational Status Tire Type Business Role S ra hype <br /> (Fill one only) (Fill all that apply)I (Fill all that apply) i (0111,all that apply) <br /> l <br /> i44 Q Active Q'Passenger Q Generator Outdoor, <br /> _ .. <br /> O a Closed Q Altered <br /> GPS Latitude . ���� Q Hauler Q Indoor <br /> ���� � Q Inactive Q Truck <br /> Longitude - I 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 @ 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 /> --- <br /> Part -- <br /> of Waste Tire Dealer, Generator, Hauler End-Use Facility �I ENFORCEMENT STATUS <br /> PInspection aseaeneraor, auer an <br /> B- p/ - --- y ' Notice Of Violation --- Extension <br /> A ,HAULING AND MANIFEST REQUIREMENTS Q Q <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 /> (Required for NOV or EXT)QQ § 1 Submittal <br /> ComprehensiverlpLogs <br /> rhiea days <br /> Q Q 14 CCR§18459.3 Retention of Comprehensive TrPLo s fo3Ys <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 Q In Compliance - No Violations <br /> Other <br /> Comments <br /> I ; <br /> r <br /> Jijl a <br /> Inspection Form inclu'dec! (� <br /> Comments Included: -- <br /> Business s Rep' Signature" Phone.Number Inspector's i�nature- Phone Number ' <br /> — --- / - 62081 <br /> INSTRUCTIONS ON BACK C-arrect:0 Incorrect: X.A WP I_ F_ 1 2 . <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� <br />