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............. <br /> IIIaWaste Tire Survey & Inspection Report inspection Report Number <br /> State of California 1143693 <br /> CIWMB 1181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Par-tA-Survey___---- <br /> I Business Profile Inspection Details <br /> Inspection Type (Fill one) <br /> TPID- <br /> Site Suffix: c2 -7 U eRoutine 0 Re-inspection 0 Referral 0 Observation <br /> Local -- 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 Inspector <br /> 0 on ilf(- L <br /> P Ical Address -S C-) <br /> Inspection Date <br /> 2_4-,4I rqp Time In AM Time Out 0 AM <br /> Business Rep Title : 0 5 0 PM 0 PM <br /> ---- Operational Status Tire Type Business 11 that <br /> apply) <br /> iness Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill a h y) (Fill all that apply) <br /> Tire Count(Whole/PTE) 6../ 0 Active 0 Passenger Generator 0 Outdoor <br /> 0 4) Closed 0 Altered N/14 <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> ieVYA440 End-Use 0 Container <br /> Longitude 0 Planned (0 OTR I- <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 Service Station 0 Hauler 0 Agriculture 0 Shredder 4D Other -we <br /> F <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENF-ORCEMENTSTAT-US <br /> HAULING V A LING 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§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 <br /> 0 014 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <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 /> 'Inspection Form Included- 01 �7 <br /> Comments Included:0 <br /> pp nature Phone Number <br /> Business UV'snatur Phone Num er <br /> 00) 62081 <br /> INSTRUCTIONS ON BACK rrect:0 incorrect: X ��C/ <br /> FC 0 E M P <br /> ■ White Copy:CIWMB Yellow Copy:operator Pink Copy:LEA <br />