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. . ....... ....... . -- --- ---- <br /> Waste Tire S*ey & Inspection Repo Inspection Report Number <br /> State of California - 1143788 <br /> CWMB181(New 04104) Survey Form - Page I Il <br /> California Integrated Waste Management Board <br /> Part -Survey__ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection Type (Fill one) <br /> Site Suffix: 3 0 l ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local +1 If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspect <br /> Physical Address <br /> C'. &3 3 9 0 hh6or Y4/n6 <br /> 3o A <br /> &o S Monroe, <br /> Inspection Date <br /> C q5c�06 (T / <br /> Time In Time Out <br /> Business Rep Title 0 AM 40 AM <br /> 9 : '5 50 PM 0 P <br /> -tt -- 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 /> 0 ® Active Passenger Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude <br /> 0 Hauler 0 indoor <br /> 0 0 inactive 0 Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 New Tire Dealer 0 Auto Repair Trucking Fleet 0 Government <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 6 Other 10C n Ll <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42951-Contracts will Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 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 (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 014 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 in compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> G4 <br /> ry <br /> Inspection Form Included: 01 <br /> Comments "0 !�ure <br /> ine, e <br /> C 1 ' 2 31 <br /> X1 I XA I T <br /> 4 usiness P s Signature Phone Number Ig ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BAC Correct: Incorrect: <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py:L <br />