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._167 <br /> rfly -4� <br /> Zz <br /> Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04/04) 1141003 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> 11 <br /> BLUE OR BLACK INK PEN <br /> A-Survey <br /> ness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: sat) 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> - 1 0 1 &'o <br /> Physical Address 9 <br /> )b03 E.H <br /> 1�4 0 CA 95JK Inspection Dale D <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM v 0 PM <br /> C <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger 0 Generator 9 Outdoor <br /> GPS Latitude ® Closed 0 Altered 0 Hauler 0 indoor <br /> Longitude 0 0 inactive 0 Truck 0 End Use 0 Container <br /> 0 Planned OTR <br /> Business Type (Fill all that apply) <br /> Jew Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> k_) 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 <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 <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 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 /> 0 014 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 <br /> In Compliance No Violations <br /> 0 0 Other: § <br /> Comments -i \i 0 i aaf'�l I-D <br /> (,lIl .,,k V0-y%kC'AN _ox)ok <br /> W"V'21 %_V 4,-, (7)07il_ <br /> N 0 ), -t' Aa 1 aws v coa% of cofl rzt n- <br /> Inspection Form Included: Q0— 1 1 <br /> Comments Included: <br /> flusinres ep's Signature Phone Nil-her ispe is Signature Phone Number <br /> 62081 <br /> S L <br /> INSTRUCTION ON BA Correct:0 incorrect: X J� XIA MIP 112131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />