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.. .... .... <br /> ------------- <br /> X <br /> ­ ------ ------- ------- ---- -- <br /> -K 0 <br /> ................ ...... <br /> Waste Tire Survey & Inspection Report inspection Report Number <br /> State of California J1 1127853 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: say\ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 7-0 <br /> Physical Address A16, <br /> Inspection Date a, <br /> CA Time In Time Out <br /> Business Rep TitleAM <br /> AM <br /> 0 0 PM 0 0 0 PM <br /> Operational 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) y <br /> ®Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude 0 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> GPS 0 0 inactive 0 Truck 0 End-Use 0 Container <br /> Longitude 0 Planned 0 OTR <br /> Business Type (Fill all that apply) 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 New Tire Dealer 0 Auto Repair Trucking Fleet 0 Government <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 116 Other „cf--, <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS - <br /> VA 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. I 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 /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB M / M <br /> / M <br /> (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 J 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 40 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> see., (DMITIEnIts <br /> Inspection Form Included: 0 Awl\ <br /> Comments Included: 0 e to s SI ire Phone Number <br /> Business Rep's Signat,,,'�Phon,N-umber l4ne to s S! re <br /> - - 1 62081 <br /> X A " <br /> INSTRUCTIONS ON BACK Correct:* incorrect: 11E XIA M L rrr I 2t3] <br /> N W <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop L <br />