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--- ------------ ..... . <br /> �7 ...... . <br /> ■ <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> kiiIIII State of California <br /> am CIWMB 181(New 04/04) Survey Form - Page 1 Il - 1143564 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A -Survey__ <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: -7 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ( If Referral,choose referral type(Fill one) <br /> S <br /> Identifier: 1'0 <br /> CL LV 1)k 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name t Inspected By Inspector <br /> �o lck'r(1)A nkit-ru'o Lt— se—tv, itts <br /> Physical Address 6e-() -ESCA0 <br /> Inspection Date <br /> cu M Time In Time Out <br /> Business Rep Title r 0 AM OAM <br /> 0 PM J <br /> a, OF% PM <br /> Role rage Type <br /> Operational Status Tire Type Business i <br /> t 0 Storage <br /> '11, <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill that apply) <br /> 0 Active 0 Passenger Generator 0 Outdoor <br /> 0 Closed 0 Altered N/A <br /> GPS Latitude Q Hauler 0 indoor <br /> 0 0 inactive Truck <br /> Longitude 0 Planned 0 OTR 0 End Use 0 Container <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 /> 10 service Station 0 Hauler 0 Agriculture 0 Shredder 40 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS--- <br /> V A HAULING AND 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 /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 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 1 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 <br /> - 0k) N)'\oVkk1N0n.5-01- cxsc-'(AS c& cooc<xo— <br /> e_ <br /> Inspection Form Included: 0 <br /> ed: Signature Comments Included: d W5 O'L-I ure <br /> gnature Inpe�orsSignIUI one Number <br /> slness Rep's -Phone Number <br /> INSTRUCTIONS ON BACK Corr ct: ncorrect: X XIA MIP'LIE! It 2 3 62081 <br /> ■ <br /> Pink Copy:LEA <br /> White Copy:C Yellow Copy:Operator ® ■ <br />