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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181( eSurvey Form - Page 1 I 1 - 1143566 <br /> California Integrated Waste Management Board <br /> Part A- Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection 1 � 104 <br /> O � ) Q - D � Inspection Type (Fill one) <br /> Site Suffix: L4 "� 1 1* Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: SOLO J Ulf) Cli n 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name _ 4 <br /> Inspected By Inspector <br /> Physical Address I.J-n Escvh <br /> L40o S . <br /> n ��� Inspection Date <br /> S`�ockL�6 C�1 `1 <br /> Time In Time Out <br /> Business Rep 1 1 ` Title ' O AM f 0 AM <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 /> * Active 0 Passenger JR Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive I& Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ® 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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> 0 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 /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 01 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 ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> jOther: § <br /> CommentswA , W. bT Ao -n—�e <br /> Ill--ct _ -(C F- - IhC, �OLWIJ)� Ea _ ao,ivir- 10of15-c-� <br /> �4SD c��, '� 1�.M = 0�111A1OR li1zv-10 1, PIIS Ilh. <br /> Inspection Form Included: 0 � ��Insperl, <br /> Comments Included: f��i �,>>W►'►� <aV` l)`1�0 1 Business Rep's Signature Phone Number ture \ 'Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect -1 1 A M I P �� I t L 31 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />