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032LO04.04.77 <br /> == Waste Tire Survey & Inspection Report Inspection Report Number <br /> eao. <br /> State o1 California <br /> CIWMB 181(New 04104) Survey Form . Page 1 11 1086904 1 <br /> califomla Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I � 9 [E�_ <br /> Inspection Type (Fill one) <br /> Site Suffix: U I0 Routine Q Re-inspection Q Referral Q Obseryation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �(�"� �� Cou/�— Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I AAS O C Ser v_1��-,�nc_.� <br /> Physical Address 3 — <br /> Street <br /> Inspection Date <br /> City "State Z!P Coaa Time In v Time Out C <br /> iffy <br /> Business Rep Title <br /> AM <br /> C; <br /> �a <br /> �O QPM I 71 OAM <br /> 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE). :� 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 J ®Active Q Passenger ®Generator 0 Outdoor <br /> Latitude <br /> GQ Closed Q Altered <br /> PS I• Q Hauler Q Indoor <br /> .i <br /> Q Inactive ®Truck <br /> Longitude — I• i I Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet Q 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 I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility IIIIENEIMMEMENT STATUS <br /> MI111H.AULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Complia ce Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or Ex�7 <br /> Q O 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I Compli n e - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments Q O �e 1 c�an e -L's— <br /> Inspection Form Included: Q tk-�—, <br /> Comments Included: 07 <br /> Business Rep's pi-gloture Phone Number Ins ct is Si re Phone Number <br /> INSTRUCTIONS ON BACK Co rest: Incorrect: A M 'L P �. 1 2 3 62081 <br /> E X <br /> White Copy.CIW M Yellow Copy:Operator Pink Copy.LEA <br />