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Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> State of California - 1143568 <br /> C,WMB 181(New 04/04) Survey Form - Page I 11 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> t A- Survey <br /> iness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: LA 5 (D 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 56tola"ql�n ((,U,.I)i� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> ---------- <br /> Business or Facility Name Inspected By Inspector <br /> �ot CINI f <br /> Physical Address I 0 I C n 9s,(,o <br /> 604 SMkon <br /> CG(_a6C\ 163b Inspection Date <br /> Time In Time Out <br /> Business Rep Title 5 0 AM <br /> o OAM <br /> 46 PM PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0' 0 Active 0 Passenger IS Generator 0 Outdkor <br /> Latitude 0 40 Closed 0 Altered 0 Hauler 0 Indoor <br /> GPS 0 0 Inactive Truck 0 End Use 0 Container <br /> Longitude 0 Planned OTR <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> U 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 ENFOLENT STATUS <br /> F—V�_-AC MULI N_G­AND 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 <br /> / 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 /> 10 1 0 Other: § <br /> Comments <br /> Jlol% ocr6inn4_ em�%k AtJv <br /> W- A-5—nof c-01 <br /> No vlo ti, n e, <br /> Inspection Form Included: 0 -7Q <br /> Comments Included: <br /> jus a Rep's Signature Phone Number Inspel's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK , Correct: incorrect: X Nf <br /> r�7X �A�, I P I L I I 112 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />