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o�i��o�oa�s <br />iiiiiq Waste Tire Survey & Inspection Report Inspection Report Number . ■ <br />State of California <br />riEa <br />CIWMB181 (New 04104)Survey Form - Page 1 �I 1 - 1108432 <br />California Integrated Waste Management Board <br />Dn.+ e _ eBLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />A <br />TPID - <br />Site Suffix: ' 13 <br />40f <br />1 <br />Inspection Type (Fill one) <br />l <br />0 <br />--oil <br />0 Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />Local <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />Identifier: <br />V� n <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 CHP 0 CIWMB 0 Complaint <br />0 Educational Visit 0 Other <br />Business or Facility Name <br />API -7 c_CM5po� <br />Physical Address <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Inspected By Inspector <br />I O I1_I—�SJ <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />a <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Street <br />LC) & ��_ <br />q%.�o <br />Inspection Date <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />City Stam <br />Business Rep Title <br />�• <br />z' ; P Ccde <br />Time In <br />_ _ <br />r --' j J O AM <br />Time Out <br />i I—� , —7AM <br />L4V 1 0 <br />0 <br />-- i- _ 0 PM <br />; PM <br />Operational Status <br />Tire -Type <br />Business Role <br />Storage Type <br />Comments L M i ret /b A-, _ _ _� A. <br />Tire Count (Whole/PTE) . <br />n <br />d� <br />(Fill one only) <br />16 Active <br />0 Closed <br />(Fill all that apply) <br />0 Passenger <br />0 Altered <br />(Fill all that apply) <br />® Generator <br />0 Hauler <br />(Fill all that apply) <br />Outdoor <br />0 Indoor <br />0 <br />GPS Latitude <br />-- <br />_ _ 7-7 -__ 0 <br />0 Inactive <br />ID Truck <br />Longitude – i , I <br />i <br />0 Planned <br />0 OTR <br />0 End-use <br />0 Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair Trucking Fleet <br />0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer <br />0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture <br />0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V I <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />a <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Ti r Dealers or Waste Tire Generators <br />1016 <br />Other: <br />Comments L M i ret /b A-, _ _ _� A. <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred/CIWMB Enforcement <br />0 In Compliance - No Violations <br />1, -* A/( -T 1A1 (,(R -ss R45 5_ '� — IWAnkAs cis -a v—, n4 <br />ction Form Included: <br />Comments Include <br />■ INSTRUCTIONS ON BACK LC <br />White Cc) <br />93- Yyi� <br />Phone Number Inspeqihes Sic <br />correct:1v(�q E X AJIMI P :I <br />Yellow Copy: Operator Pink Copy: LEA <br />AE -3 _11A_ <br />Phone Number <br />62081 <br />® ■ <br />