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Waste Tire * ,_ vey & Inspection Repf Inspection Report Number <br /> ■ I!i State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I1 - 1140931 <br /> California Integrated Waste Management Board <br /> Part A- Su"e - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O � � I Inspection Type (Fill one) <br /> Site Suffix: 1 ` 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ��� O F (�y)AIA <br /> IfReferral,choose referral type(Fill one) <br /> Identifier: ��rN 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name _ Inspected By Inspector <br /> FOS Wu,jd, 1)C,' <br /> Physical Address 3 9 <br /> n&e w, <br /> C� I533� Inspection Date <br /> CA <br /> Time In Time Out <br /> Business Rep Title �j O AM O AM <br /> o l <br /> U - - - - - - - - - <br /> -- --- - v` � -- C 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 /> a Active Passenger ® Generator 0 Outdoor <br /> O 0 Closed ®Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive � Truck <br /> Longitude - e OTR End-Use ® Container <br /> 0 Planned <br /> i <br /> Business Type (Fill all that apply) ---- -- - - -- - - - <br /> 0 New Tire Dealer 0 Auto Repair 0 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 I® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> O O <br /> 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 je 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 EXE <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 0 Other: § <br /> Comments f v ' t 0 f MR UA � 8C 4-0A <br /> Inspection Form Included: 01M , <br /> Comments Included: — 1 \ J41�` <br /> Business Reps Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:is Incorrect: X X A Z 2_[3 62081 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Co y:L ® . <br />