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i,,A Waste Tire Suy & Inspection Report Inspection Report Number <br /> State of California 1 <br /> CIWMB 181(New 04/04) y urvey Form - Page 1 [ I + — 1127616 <br /> California Integrated Waste Management Board _ .......... .._.... <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business ProfileInspection Details <br />} TPID- , . (/ _ Inspection Type (Fill one) <br /> Site Suffix 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> �r <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 0 '{ Inspected By Inspector j <br /> - <br /> �y <br /> "�Y f, lJL2 Y•..+ k`.4 4F i ,.E� +`tet 16LE Physical AddressJ �'�Ali r� �� � 5 <br /> 106 U, ��, t ,r e� <br /> - (,I lit%� <br /> stree. _ ; <br /> 0I - <br /> Inspection Date j li I 0 ?' ' <br /> `r✓s� .1 l A vet, t `�J ......_...... <br /> L_._.__ <br /> 1- .. :pife Zip Code Time In Time Out <br /> Business Rep Title AM <br /> a O P fir-- O AM <br /> { Y <br /> i O PM O PM <br /> ill :01% ___..._... _.._. _.... _ -.-.-... Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that cuply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole,IPTE <br /> 9 9 <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude <br /> 0 Closed 0 Altered <br /> GPS . i 0 Hauler 0 Indoor <br /> __�_.m 0 inactive 0 ruck <br /> tom_ r <br /> Longitude _ _ ........}_ I ..__. _ ._. ._ _ O 0 End-Use Container <br /> g . ' 0 �i 1 Planned OI R <br /> i <br /> i 9 1 <br /> Business <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 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 0 0 <br /> Notice Of Violation 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 <br /> m , m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB M / <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 /> 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 1 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: <br /> Comments I: (t r>i ` 4 �• _ �F <br /> l i?f r f � ►t L( �✓Z 1 ti ' or ( ��� ���J �. ��i�/1�' to Pk .%:; <br /> fA / <br /> Q11 r' COP, S�1Ga:�1�Yt P 4th etc word 5 at"J.:tj/� � ((7��.tf�:�:' L`-ctIfF.d rC �l �I / <br /> �^ art t ., 111 rl(�rrp�,lll:'��'r'iT !+..� (�;11, !i� !��rt-F .�-J��� ! a., ,+}r. l} "T <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 1r 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � � �,�_���`� � � � � � 3 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />