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--- -------- .... ... . ----------- <br /> .......... <br /> �ft <br /> ■ <br /> HE, Waste Tire Survey & Inspection Report inspection Report Number <br /> 1143972 <br /> State of California <br /> CIWMB 181(New 04/04) <br /> 1 W170 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: LI <br /> 0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 59 A-rccm6,)1c\ <br /> Physical Address <br /> lo-15 inspection Date P5 <br /> tttill,�-Ccc, Time In Time Out <br /> 0 AM 0 AM <br /> Business Rep Title PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> I <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) lie 0 Active 0 PassengTere Generator ® Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> 0 0 inactive ®Truck <br /> Longitude 0Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair S 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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Compliance Deadline <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB (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/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 1 0 Other: § <br /> Comments "Set <br /> Inspection Form Included: 71 <br /> AP <br /> Comments Include pct s Ig ure Phone Number. <br /> Bi Ph Phone _§er t <br /> s <br /> Busines Signa ure Phone Number <br /> 62081 <br /> * Incorrect: A ,V <br /> INSTRUCTIONS ON BACK Correct: - _ <br /> White Copy:CIWMB Yellow Copy:operator Pink Copy:LEA <br />