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® Waste Tire SuNey & Inspection Repora Inspection Report Number, ■ <br /> State of California <br /> Wil <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br />} Site Suffix: J 1 -7 15 0 11 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local , �_o <br /> 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 v <br /> Inspected By Inspector <br /> Physical Address ,ash OU-t" Ale L�S 1 cr) b-cf _—IL, Lo 11-1 <br /> Street <br /> Inspection Date (� � / F2 I q ET) J8 <br /> 1--�._ d C" . .s�'� ------- �-'---_—T_'�'�Ot Time In Time out <br /> State � <br /> Business Rep Title AM — �11 0 AM <br /> 0 PM 0 PM <br /> "_.�_""'"".. "_. __, s,� JS✓lrl`._.�, Operational Status Tire Type g yp <br /> CC e <br /> Business Role Stora e T <br /> The COUnt(Whole/PTE} (Fill one only) (Fill all that apply)': (Fill all that apply) (Fill all that apply) <br /> iIyYV i <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS , Latitude M , ILL <br /> � �' 0 Hauler 0 Indoor <br /> 444 Truck <br /> 7-T-7-7 <br /> _ TvT - 0 Inactive 0 <br /> . —._� �_. ._ 0 <br /> Longitude - -�P --7 __ 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 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> 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 <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 f 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 0 In Compliance - No Violations <br /> 0 0 Other: § - - - - -- -_J <br /> Comments <br /> Fact,\ b - ����i�- ✓1r t 1�� I f u f� �'o[ '�,X�? `;2 t-V I c 3 're"-\CAV(1 <br /> �tC� ..-.,�sc;�,r� C�'(�'�►7�.--5���[�J`,�h -�"��et ��1 (�`�"211�Y�C � .� '�- (-t• r' <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X µ A 14 1 I L <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator _ Pink Copy:LEA ■ <br />