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Dal 82.04.02.02 <br /> CHU <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State B 181 California Survey Form - Page 1 1 1 - 1 0 7 9 3 5 6 <br /> CIWMB 181(New 04/04) Y ry <br /> California Integrated Waste Management Board y <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` S 7 � - I • Routine 0 Re-inspection Q.Referral 0 Observation <br /> Local 7\ If Referral,choose referral.type(Fill one) . <br /> Identifier: LS—aw n /ly�,�f1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business r Facility Nam��V11 ��"-J Inspected B <br /> 1 P y Inspector <br /> Physical Ad ress <br /> Lilolil <br /> & <br /> s 2ee—�� <br /> tr ( <br /> Inspection Date <br /> (—_V�� (A 15MI <br /> City State Time In Time Out <br /> ZIP Code <br /> Business Rep Titlec\ 0 AM 0 AM <br /> r 1131 ' �J 0 PM L—Lil : y 5 % PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r I Active ® Passenger 0 Generator •Outdoor <br /> J <br /> 0 Closed 0 AlteredGPS Latitude ( 0 Hauler 0 Indoor <br /> I_ -L——_..I— 0Inactive 0 Truck <br /> Longitude Ll_10 <br /> 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Q 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 I I <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 <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 /> 0 . 0 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 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 NOVorEXT) <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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I* In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments �VW- <br /> J <br /> _ov VL <br /> Inspection Form Included: 0 -1 ` <br /> ��f�3S <br /> a1��� <br /> Comments Included: 0 -- &�+Wature <br /> - <br /> Ine s Signature Phone Number InsSignPhone Number <br /> 62081 <br /> INSTRUCTI ON BACK C rrect Incorrect: &V R A M P ;L l 2 3 <br /> ■ White Cok CI Yellow Copy:Operator Pink Copy:LEA <br />