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=_ Waste Tire .sur „ay & Inspection Rep(,, t Inspection Report Number <br /> tiffs State of California <br /> C,WMB 181(Nw 04104)California Integrated Was eeManagement Board Survey Form - Page 1 I 1 - 1140756 <br /> dart A-Survey BLUE OR BLACK_INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � `7 � � _ M I Inspection Type (Fill one) <br /> Site Suffix: v 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier. {� �� �IJ�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> bo(\ LAUA_� Co . Inc . - b <br /> Physical Address <br /> DI 1-0 Lo om - <br /> S�a � � T-5.205Inspection Date I <br /> 1, I,�yyriV` Time In \ Time Out <br /> Business Rep Title u O AM O AM <br /> 1 1 O 0 PM It 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 /> ��'J <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O Closed Altered //��ll ry <br /> GPS Latitude A 0 0 Ha(Jltdroq 0 Indoor <br /> p 0 Inactive 0 Truck'��'1 <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <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 Other "JfjwI ) I I�(YlglJl CUl <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A !,HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 § - 0 Notice Of Violation 0 Extension <br /> PRC 42951 Waste Tire Hauler Registration and Transport of Tires <br /> '0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 i 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 114 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 '114 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 <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 : 0 Other: § <br /> Comments ILOUTIr%UNo l�G�ife-. �l(v lrl`��EUP1ti1� �e�"f(7fr(1Q/A �� 1/11� f ►L GITI(/� �n1�VWN`G� <br /> I <br /> NAC1. no6es 'i� �,us; ss his loc�t�;an_ C(o . zf D. <br /> Inspection Form Included: 01 <br /> Comments Included: 0 --- - - - --- <br /> Business Rep's Signature Phone m r Inspe is Signature Phone Number <br /> ,-/ 62081 <br /> INSTRUCTIONS ON BACK Correct_ Incorrect: i NI (E RC1 A M �EeA f 1 2131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:Vf <br /> ■ <br />