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Waste Tire Su9ey & Inspection Repor* _Inspection Report <br /> Number ■ <br /> ® State of California 1 1 - 1088339 <br /> CIWMB 181(New 04/04) <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board ��� -�---�-------- - - -- <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> _ _ r <br /> - Ins ection Deta <br /> Business Profile ils� p <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix d .� � t I & Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> � <br /> Identifier: +�..r� u_ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> . :i '�' f'►'!['-sem- ���n Y� �►' tr(C:..�-r <br /> Physical Address —^�- - f �'S l !\ ✓C i `>,- J <br /> Street <br /> Inspection Date <br /> 1. J <br /> .mss._ <br /> B — -- --i Time In Time Out <br /> +, �t=at� /Its Cade M :ET-- <br /> usiness Rep Title � OAMO AM <br /> 1 , -- � 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fillone only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger i Generator 0 Outdoor <br /> 10 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 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 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 /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / FTI / FFI <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 NOV or EXT) <br /> 0 O --- - -- <br /> 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 /> ,f <br /> 011 <br /> 0 14 CCR§18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators (g) In Compliance - No Violations <br /> 0 (Other: § <br /> j <br />, Comments ; - C-) <br /> f CVS( /rl= � <br /> , i <br /> � _ �:��r)��C_:� � �l (,cJtt yf-E-� ff�.� �•�rM U l� d� 1�1 � S-� I <br /> I i ,�? � ►� !��' c �`� ✓u} <`P L � 1-tit n°�t f .S S i/IrP �'d <br /> -- <br /> Inspection Form included: <br />¢ <br /> Comments Included <br /> Incl_uded' <br /> Business Rep's Signature Phonet,Number t tr_ ,.._h ,, <br /> Phone Number <br /> Is ector s i na „H <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:(® Incorrect: X Ake <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />