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------- ------------- - - --- --- .......... ....... ....... <br /> ---------------- <br /> Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> StateOf California <br /> CIWMB 181(New 04/04) 1144024 <br /> California Integrated Waste Management Board Survey Form - Page 1 BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> BusinessProfile Inspection Details <br /> - - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3- o_� 0 Routine 40 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �XkV N 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> C <br /> Physical 4 dress 1 <br /> Inspection Date <br /> 64 q54�) Time In Time Out <br /> Business Rep Title 0 *0 'P'M' '0 AMM <br /> 06j Y-e <br /> \j Operational Status Tire Type Business Role Storage Type <br /> ype <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 16 Active 0 Passenger Generator ® Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 0 inactive Truck 0 Hauler 0 Indoor <br /> Longitude 0 Planned 0 OTR 0 End-Use ® Container <br /> Business Type (Fill all that apply) <br /> New 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 0 car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other Ayr— <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility -ENFORCEMENT STATUS <br /> V I A mutuNG 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 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (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 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: 0 Fj�7S <br /> Comments nc uded' <br /> BYs, Rep's Signature Phone Number I S d ignature Phone Number <br /> J <br /> INSTRUCTIONS ON BACK I Corr t. Incorrect: I VI E X AO <br /> - L14 1113 62081Z <br /> ■ White Copy: B Yellow Copy:Operator Pink CLPYJN © ■ <br />