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• z _.. <br /> LL3 <br /> Waste Tire Sur,,ay & Inspection Repo. Inspection Report Number ■ <br /> oo= State of California I 1 - 1141033 <br /> CIWMB181(New04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 � Inspection Type (Fill one) <br /> Site Suffix: I* Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S n J pqq i n Dun'`"1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J Inspected By Inspector <br /> Physical Address <br /> \ `]� 55 ComconeX - - - - <br /> M (AI*C CX, CA `1535 Inspection Date _1 l <br /> Time In Time Out <br /> Business Rep 11-- Title {� //�� 0 AM 2 O AM <br /> Gk4 5 ( � V ` PM J 3 O � PM <br /> - - "- ----- --- ----- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> �„/ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ((`/'J <br /> f 40 Active 0 Passenger 4D Generator 0 Outdoor <br /> Latitude O 0 Closed 0 Altered NA <br /> GPS 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> i <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 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 /> 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 1 ENFORCEMENT STATUS <br /> VIA I HAULING AND MANIFEST REQUIREMENTS <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 <br /> m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB M <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days i (Required for NOV or EXT) <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 /> 1010 Other: § <br /> Comments i,\,_ lKX \is I f)V eLAL-,, 1115 <br /> g <br /> Nm ` c C)_Suwcgs ��Wccm� <br /> Inspection Form Included: 0 <br /> Comments Included: ® �- - - - ---- <br /> usiness Rep's Sign t re Phone Number Inspe is Signature one Number <br /> INSTRUCTIONS ON BACK Correct. incorrect IR/ <br /> 62081 <br /> E A 011,_ii I <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop( <br /> L A <br />