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,. Waste Tire Su. -ey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 I 1 - 1127468 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey_ <br /> Business Profile Inspection Details _ _- <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: t C2 l �y L _ 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier. San / QCHP QCIWMB QComplaint Q Educational Visit <br /> Other <br /> Business or Facility Name Inspected By Inspector <br /> "Ad resd\es 1-LLC- 3 - ( iso �►�mbvlc <br /> Physlca s J <br /> 5nOO 5 . <br /> Inspection Date 1 Z- Q o <br /> Time In Time Out <br /> Business Rep Title AM 1 ® AM <br /> 0 PM 0 PM <br /> �GtVyYIU Y`cC� <br /> Operational Status The Type Business Role Storage Type <br /> Q <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 1 Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned Q OTR Q End-Use Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair o Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 1 HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle �, ,� <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Mt <br /> / �( )� � <br /> Q Q 114 CCR§18459.1 -Tire Program ID Number from CIWMB I or I I I <br /> Q Q 1 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O -- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _. <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> sem �wnme -_� <br /> Inspection Form Included: * aU <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number _ In e to s ignature _ Phone Number <br /> - -- -- - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: \/ i\� ✓ 1 ' <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py ® ■ <br />