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® Waste Tire SJ&y & Inspection Reporo Inspection Report Number <br /> State of California <br /> CIWMB 181(New04/04) Survey Form - Page 1 I 1 1127631 <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: �p - �+ 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local [ If Referral,choose referral type(Fill one) <br /> Identifier: ( a6ak 01( I} 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name lei Inspected By Inspector <br /> roo <br /> Physical Address <br /> f Nrac a <br /> �-__.........�_tai......_...m..____.....__...._....._� _.._.._.....�....,...._....__.. ... __..._..---..._..._s rv--- <br /> In I <br /> i <br /> Sfieef Inspection Date <br /> ZfP '<sc Time In Time Out <br /> Business Rep Title j i O AM (f O AM <br /> 11W� � � .. *� QPM / 1 0 P <br /> t ... " r� �.yv ""�'" Operational Status Tire Type Business Role Storage Type <br /> -'_7 <br /> Tire Count( thole/PTEA r (Fill one only) (Fill all that apply) (Fill all that apply) ;Fill all that apply) <br /> y <br /> A 0 Active D Passenger 0 Generator0 Outdoor <br /> Latitude 7_7O 0 Closed D Altered <br /> GPS �� t 0 Hauler 0 Indoor <br /> �--- - —'- ---' 0 Inactive 0 Truck, <br /> T.__._ . _,....._.... .-.__.. D <br /> I , <br /> Longitude - ( 0 Planned CJ OTR0 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 Fu� <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 REQUIREMENT'S <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 m M / m <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 orEXT) <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 1 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: § - <br /> Comments <br /> �cdAl I a- TT�' <br /> s_ rAt� �1 �-es I- :r r�e . L'rL � ,i (� c <br /> -InSpBCtiOn Form Included: 0 'sw..:,.� �� -.'4 'a�'r ?�,: .er1'n �G� "�y ��"� m: ,� a`,, ..,. ;,H. <br /> .. € <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's! na y Phone Number <br /> - _ m <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �t (- t` ,,A t� P'., � � 3 1 , 2__ 3 6201 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />