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Waste Tire SAO & Inspection Repol` spection Report Number <br /> ■ <br /> ■ r^m6iw 2 State of California 1 1 - 1088024 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board - -- <br /> Part A- SurveyINK-PEN- <br /> BLUE OR BLA <br /> Business Profile Inspection Details _ <br /> _ 3 <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: { ` (9) Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localan' U lin C un-� If Referral,choose referral type(Fill one) <br /> Identifier: 1 p 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name— Inspected By Inspector <br /> n it- <br /> Physical Address —� - <br /> 31_9_! ! _� B rtstl an LuCaS .-J <br /> L_���_► � t�h and u,.__s C-_.. __.,_. —.-- ---... <br /> Street � -�,-_____`_...__� <br /> _ Inspection Date i ! 10 / 1,T� 01 <br /> I In <br /> City Slate ZIP Code Time _ Time Out_._ <br /> BusheRep Title ` O AM O AM <br /> O PM O PM <br /> s' <br /> leo_ B rich M - <br /> Operational Status Tire Type Business Role Storage Type <br /> O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger ', ® Generator 0 Outdoor <br /> — O 0 Closed 0 Altered <br /> GPS Latitude <br /> EIJ . ��T 1 Hauler 0 Indoor <br /> j - O 0 Inactive 0 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 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 / Ffl / M <br /> 0 1 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 NOV or EXT) <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 i 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 (5 In Compliance - No Violations <br /> 0 0 Other: <br /> Comments <br /> ollokuli-I n + WaL n©fid <br /> �,�voIU �aafe�u �►r �recP ten;�l e t5 c�_ct�►� —tom IOU)-VOILA <br /> _ eh�r o _. Fac tales RrcannorN, 74re- cwt ,f ieA Ire r-0M_\j.ai <br /> 7e L <br /> Inspection Form Included: 0 1 <br /> ,,.... <br /> a <br /> Comments Included: 0 + J <br /> Business Rep's Signature Phone NUrnber ln�pectfsr s Signature Phone Numb r <br /> ✓X � ® g_ A, 1 I °-1 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �/ d � P � � � ",�� <br /> aWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />