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Inspection Report Number <br /> Waste Tire Sutvey & Inspection Report <br /> ■ <br /> State of California 1127880 <br /> CIWMB 181(New 04104) Survey Form - Page I <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- <br /> Inspection Type (Fill one) <br /> 01 Site Suffix: 0 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 /> 1111 <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 39 - <br /> Ln <br /> CA q 5 a Lic-) Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> PM 5 OPM <br /> rimOperational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) Active Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 0 inactive 0 Truck 0 Hauler indoor <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 N-ew 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 jo 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 /> 1 HAULING AND MANIFEST REQUIREMENTS 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 Datem / m / M <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 I 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: 01 <br /> j ig.3 86,09. , <br /> I - . L 7V <br /> !' ^ <br /> Comments Included: lillil, <br /> Business Rep's Signature Phone Number ns for tbrgrature Phone Number, <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect:X( � 1 ! 2 3 <br /> IV <br /> White Copy:CIWMB Yellow Copy:Operator ink Co <br />