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................. <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181 W (New 04/04) Survey Form - Page 1 11 - 1140780 <br /> ed <br /> California Integrataste Management Board <br /> I A- Survey BLUE OR BLACK INK PEN <br /> ;iness Profile Inspection Details <br /> TPID- nspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit U Other 11 <br /> Business or Facility Name Inspected By Inspector <br /> �o n d� F��nh, ��c} t 0\1j <br /> Physical Addres 3- 1 - 0 1 &n lFs co-h <br /> cAllss;o Inspection Date 0 <br /> Time In Time Out <br /> Business Rep Title OAM OAM <br /> IS PM I I 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 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 *Closed 0 AlLered /V/,n <br /> pS Latitude 0A <br /> G Ha 0 Ind <br /> 0 inactive 0 T u 1A 0 uier— oor <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Rusiness Type (Fill all that apply) <br /> Vew Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 <br /> M <br /> 010 14 CCR§18459.1 -Tire Program ID Number from CIWMB M 17 <br /> (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 ek In Compliance - No Violations <br /> 0 0 Other: <br /> Comments o _k_ Aile-, I �)-5'ozjbn V)ee�-6jr <br /> a+e <br /> %J <br /> -f) <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> 0, Is Phone Number Number <br /> r C-� 11�`�" �� <br /> Business Rep Signature- Inspect s,Signature <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X Ap V E X1 A MI P L I C-1 I I ' z 1-1] <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />