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Waste Tire SAM 6y & Inspection Repor-O Inspection Report Number <br /> -� State of California <br /> CIWMB 181(New 04/04) Survey Form Page 1 I 1 1088182 <br /> California Integrated Waste Management Board - �7 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile — 'Inspection Details <br /> _ <br /> TPID- I ' 1 ,51 <br /> 1 � CzInspection Type (Fill one) <br /> Site Suffix: •� Q Routine O Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sr"r'+ To Gq U t n �Un�'y O CHP O CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector " <br /> u cls a1c -T"n c . i 3 <br /> Physical AddressTI L u c a s I <br /> I U 83 U S . 14Qr I On <br /> Street [�D]3 <br /> Inspection Date ® 8 / lilr. / <br /> F1r e n 6-) Carl D C A 9�Z31 <br /> rihl I State ZIP Code Time In Time Out <br /> Business Rep Title I O AM AM <br /> O PM _ O PM <br /> '1,GC}C%q K C ,n 5 <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> jjjj� r ,. �} Active Passenger ® Generator Q Outdoor <br /> m D Q Closed Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> Q Inactive Q Truck N/A <br /> Longitude - I Q Planned Q OTR 0 End-Use 0 Container <br /> Business Type (Fill all that app <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other Tr u 0- C_Q, <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / FF <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 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: § <br /> Comments �t .1 t orCj ±})I C)n�e 1"U)1OvJlr�ct <br /> Ylr �d FGCt`\�u u:�2� MCCAu Truck <br /> _T\(--e_ Se[V tce etn_e znc or <br /> IL)CA �� �1r2 rrmoVCA TC Um IsT0 NG `\Ve`:. _S [C)fery on- <br /> !.(-)O-z t'A-0-C) <br /> Inspection Form Included: Q i <br /> p g <br /> Comments Included: Q _ .. �:�c,c.--. <br /> Business Re s Si nature Phone Number r In ctor's Signature - Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK .Correct:* Incorrect: X i Am I_PT L � 1 � 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />