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. . ..................... --------- <br /> -------------- <br /> ------------ <br /> _­­............... <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> 11a ClWMB 181(New 04/04) Survey Form - Page 1 1 1143562 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part-A- Survey -- -- - I - - ___ - - I <br /> i <br /> Business Profile Inspection Details <br /> TPID- aInspection Type (Fill one) <br /> Site Suffix: Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S':A-0'JOa�U'IrN cw-'A 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> `�es m'l(-).L\ c.%.s <br /> Physical Address o ki\ Escott-o <br /> (N) C(Jro 9 CA llsas� Inspection Date D <br /> Time In Time Out <br /> Business Rep Title0 AM 0 AM <br /> � : 0 0 0 PM (a PM <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 /> ®Active 0 Passenger ® Generator Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> 0 0 inactive 9 Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <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 Agriculture 0 Shredder -�t r <br /> 0 Service Station 0 Hauler r Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility FENFORCEMENT STATUS..------. <br /> -V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 I 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 <br /> / m / <br /> 00 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB (Required for NOV or EX7) <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 In Compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> sc- ()5 <br /> N onS ©S Ck(urA <br /> Cos <br /> :Inspection Form Included: 0 <br /> O&r'fs Sign, <br /> `��K�7N� C�� ���'�I_/O <br /> Comments Included: P <br /> g'L"� Inspe <br /> Business Rep'sS� Phone Number Inspe is Signature hone Number <br /> 62081 <br /> It 21�3 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X, A M P <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />