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Waste Tire y & Inspection Repoft Inspection Report Number ■ <br /> ■ -ilii State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I 1 - 1143799 <br /> California Integrated Waste Management Board <br /> PPart A-8urvey_ BLUE OR BLACK INK PEN <br /> art -- -_ - -- - --- -- - - - - -- - - --- - <br /> Business Profile 1 Inspection Details <br /> TPID- , r� � n' f� � � _ � 1 Inspection Type (Fill one) <br /> Site Suffix: pl `� ® Routine Q Re-inspection O Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCAB J U`n ��ll t1 "\ O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name J <br /> ` Inspected By Inspector <br /> Physical Address <br /> ^ 3 CS(Q <br /> 4cco_Amo Ave-- <br /> nspection Date � � I X � lo <br /> C A 9�bq I <br /> IT(dktTime In Time Out <br /> Business Rep Title_ e r 0 AM (� 0 AM <br /> C )Q1'yl(L J \J of <br /> � ®PM PM <br /> JQ �n C,US�4\b y- 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 O Passenger Generator O Outdoor <br /> 0 O Closed O Altered <br /> GPS Latitude O Hauler Indoor <br /> O O Inactive ® Truck <br /> Longitude – O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) _ <br /> O New Tire Dealer O Auto Repair I* Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other <br /> Part B- Inspection of Waste Tire Dealer Generator Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953 Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O - - - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred f CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 014 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O O Other: § <br /> Comments ►/ OU1��(V 1\�S �of�__{)(1'►� �1 11R – � � 1- �A� � <br /> (�D V\A(kkr n n( b s <br /> CA e,1 F s m ed. <br /> Inspection Form Included: O _-- 07. �Sintur, <br /> `�'�-�},,�Comments Included: �w►w �nusiness Rep's Signature Phone Number InspePhone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> ■ - _ ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink C y:L <br />