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® _ Waste Tire SAey & Inspection Reporp Inspection Report Number ■ <br /> 3 State of California I 1 - 1088413 <br /> Survey Form - Page 1 <br /> w�9 CIWMB 181(New 04/04) <br /> California Integrated WasW Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> ``- ins ection Details ` - - - <br /> - --y <br /> _ - p <br /> Business ss Profile <br /> TPID- ` <br /> ` � _ L21-ijRoutine <br /> Inspection Type (Fill one) <br /> Site Suffix: '� t Q Re-inspection Q Referral Q Observation <br /> Localy If Referral,choose referral type(Fill one) <br /> .)O GQ <br /> Identifier: a l n coo t <br /> �Gn t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �! Inspected By Inspector <br /> I_M�a h��rCorp0r-oklo'n Arn,e.ucaj 3 � <br /> Physical Address <br /> N,_.r tw o c c ojo SAY,. J — — - _- <br /> Inspectio <br /> �'sStreet <br /> n Date <br /> iBusiness Rep — ^— Title State ZIP Code <br /> Time In F � AM Time Out ._.__- --.. _ O AM <br /> __-_J ---_-_ _ O PM PM <br /> C t�it1L�1,'J..�1�. -_ _ <br /> ���, —I�� - -� Operational Status Tire Type Business Role Storage Type <br /> The Count (Whole/PTE) - s (Fill one only) (Fill all that apply):1 (Fill all that apply) (Fill all that apply)'. <br /> T771; Q Active Q Passenger Q Generator Q Outdoor <br /> 1 O ® Closed Q Altered <br /> GPS Latitude - ���- Q Hauler Q Indoor <br /> ������((( Q Inactive Q Truck <br /> Longitude m Q Planned Q OTR <br /> ` " Q End Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ' Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Fppci p�o cESs i nc1 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility -ENFORCEMENT STATUS <br /> VA 1 HAULING AND MANIFEST REQUIREMENTS <br /> Q QQ Notice Of Violation Q Extension <br /> I PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 4Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of\Comprehensive Trip Logs for 3 years <br /> Q O14 CCR§18460.2-Manifest t System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 0 in Compliance - No Violations <br /> Q Q Other: § L <br /> Comments No -�C-()j.9C —)+P._ <br /> Co, Od i <br /> l.+ <br /> Mc��1-r�r+Rf _S c_��} urr-en�-� �Joc�yes �h��_ lc)c a-'r or- . ?, commo—n6 -t o c toS p— <br /> p " Included: _ <br /> Ins ( .� <br /> ection Form Inclu <br /> Comments included: Q sly."0 16(u(`_t <br /> Business Rep's Signature Phone Number I ctor's Signat r Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: MEJ 11,1213. 62081 <br /> SWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />