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.............. <br /> ........... <br /> - --- -------- _.:._­' - -- <br /> Inspection Report Number <br /> �1 <br /> Waste The Survey Sc Inspection Report <br /> State of California <br /> CIWMB 181(New 04/04) Page 1 1140699 <br /> California Integrated Waste Management Board Survey Form BLUE OR BLACK INK PEN <br /> Part A- Survey, <br /> Business- --Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 62 fti Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S'O'q 'Crtco 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> �11 - <br /> Physical Address i o <br /> ao- (9-qcx-f L-ri, ,- A Asa ' Date <br /> SSIL-4-T Time In Time Out <br /> Business Rep Title (D AM AM <br /> I I : 0 CD 0 PM 0 PM <br /> 4A,,,4- Operational Status Tire Type Business Role Storage Type <br /> Operational <br /> one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (00 ct <br /> Tire Count(Whole/PTE) ✓ <br /> ®Active Passenger Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 0 Inactive 4&Truck 0 Hauler 0 Indoor <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 Q 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 /> : <br /> _ <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other L'X ,k <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST 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 / / [T] <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB (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: 0 5 -7 <br /> 17 -e16 X <br /> Comments Included: 4111 nature Phone Number <br /> Business Rep's Signature Phone Number _s <br /> INSTRUCTION 2 62081 <br /> S ON BACK Correct: Incorrect: X 1E X A 1 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co V <br />