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eaa <br /> Waste Tire St., „ay & Inspection Repo .. Inspection Report Number <br /> State of California 11 - 1143698 <br /> CIWMB181(New04/04) Survey Form - Page 1 <br /> Califomia 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: C2 Is D 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 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 Inspected By Inspector <br /> A i 1 Amen-c^ 0"'-�OY <br /> Physical Address 3 _ i <br /> l l <br /> et <br /> 1.� Inspection Date -7 <br /> Time In Time Out <br /> Business Rep Title / /- AM r- ® AM <br /> Pao le � l t I�C'�'� G' O QPM <br /> -O PM � � � `-'� d <br /> cyl <br /> Operational Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> 0 Active 0 Passenger ®Generator ®Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude Hauler 0 Indoor <br /> O <br /> Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair ClTrucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® 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 <br /> Ai HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q 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 or EXT) <br /> 0 - --- <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 /> 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 \ w-S Oy— a <br /> R P Znsp� �f'> r7t�[' �- I VI iZ. �G rG o /4 .f?�''l ,.77 <br /> tG►2't_�r1�-�' a All A-vne�, c►�1'�-n�Z2 <br /> _ �3 <br /> PTYJ <br /> Inspection Form Inc uded: 0 Lt <br /> Comments Included: 0 <br /> Business Rep's Signa ure Phone Number s g ure _ _ Phone Number <br /> — <br /> 62081 <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect. � .`Y V� � L � 3 . <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pin :LEA ® ■ <br />