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. f <br /> Waste Tire Suy & Inspection Repo O1, Inspection ReportNumber <br /> Clan" State of California <br /> CIWMB 181(New 04/04) <br /> Survey Form - Page 1 �~ I 1 - 10 8 8 4 01 <br /> California Integrated Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Profile j Inspection Details <br /> TPID- Fn F[7-7] _ U Inspection Type (Fill one) <br /> Site Suffix: "[ # Routine O Re-inspection O Referral O Observation <br /> k <br /> Local V OA�"Ui fl .wt�rpt If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> I Connell -7%y-,e Se.rVlce <br /> Physical Address a i �✓ �l�rlS�Gn LalCgS j <br /> J' <br /> i 22- N. l Son uJaH I i <br /> Street <br /> Inspection Date <br /> C 95-2051 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title UE <br /> 0 AM 0 AM G.. Q PM O to PM <br /> Ghr is I"I►11on idc� , . 4�iGe M � <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 /> 1� �. a O <br /> Active Passenger Generator <br /> _ � O 9 � �Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude m . ® Hauler 0 Indoor <br /> O <br /> Inactive Truck <br /> JLLjLL0 <br /> i <br /> Longitude .- lanned 0 OTR O End-Use Q Container <br /> . - -------------- <br /> Business Type (Fill all that apply) \ <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government Q,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 #Hauler 0 Agriculture 0 Shredder 0 Other I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS ' <br /> V A i'HAULING AND MANIFEST REQUIREMENTS <br /> 0 .O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation 0 Extension <br /> 0 .O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRG§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible,Entities Complying with Manifesting Requirements <br /> Date m / m / <br /> O O -14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) :\ <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 I CIWMB Enforcement <br /> 0. 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ — <br /> 0 0 114 CCR§18462-Manifest System Requirements.for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 O Other: § <br /> Comments <br /> T�ou�C��__*,ns -} toter� r�ori^n.4.d��'l7ls ale o t�J)n as <br /> d �o <br /> rsa _e�l�� c—off. 1. 30 _ ante ��es ;to reeJ ANOZAclQ L451 <br /> t, <br /> CoA�,+r,-er 1 ep ohsr�-e . 'FcxcAAq uses Czouzn- gnu- Prnjuc,,�$ ar i <br /> h aver bai r -t iY%e t,�-r-e <br /> Inspection Form Included y� x - - J - �Z U q - — <br /> : .. <br /> Comments Included. <br /> Business Rep's Signature Phone Number 'P' In is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK ; Correct:* Incorrect: xx � . 31 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ - .1 <br />