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-- ------------ <br /> EZ, --- <br /> ■ <br /> Waste Tire Survey & Inspection Report inspection Report Number <br /> State of California 11 — 1127852 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> call"OnniaIntegrated Waste Management Board BLUEOR-BLACK INK PEN <br /> Part A-Sury <br /> Inspection Details <br /> Inspection <br /> Business Profile <br /> Inspection Type (Fill one) <br /> T <br /> n <br /> TPID t 0 Observation <br /> Site <br /> Suffix: <br /> Routine <br /> "ine <br /> 'te x_ c�, E5 'k ID Routine 0 Re-inspection 0 Referral <br /> ite Suffix: <br /> If Referral,choose referral type(Fill one) <br /> Local 0 Complaint 0 Educational Visit Other <br /> Identifier: 0 CHP 0 CIWMB <br /> Business or Facility Name Inspected By Inspector <br /> AC '- <br /> rX I q <br /> Physical Address S 1 0 yqtkV_1-__1 Ay4mbu <br /> Inspection Date g t I t <br /> CA q5SL216, Time In AM Time Out 0 AM <br /> Business Rep Title t 0 PM 0 OPM <br /> �v c. Business Role Storage Type <br /> Operational StatusFf,,e iyp, 't PIYF <br /> 11 that <br /> apply) <br /> (Fill all that app, <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Outdoor Tire Count(Whole/PTE) Active 0 Passenger Generator Outdoor <br /> -,ger <br /> 0 Closed 0 Altered <br /> ,Tn , r Indoor <br /> GPS Latitude 0 inactive ® Truck <br /> 0 Hauler 0 indoor <br /> 0 0 Planned 0 OTR 0 End-Use 0 container <br /> Longitude <br /> -------------— <br /> Business Type (Fill all that apply) Government 0 Retreader Q Dismantler 0 Tire Derived Fuel <br /> li&Truckin Fleet <br /> 0 New Tire Dealer 0 Auto Repair <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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility rENFORCEMENT STATU-S- -- ---- <br /> IV 1 0 Extension <br /> I A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> TR 4 2 9 75a Waste Tire Haulers. Compliance Deadline <br /> P C§ 1 -W s I I <br /> 0 0 PRC§42953-Contracts with Registered Waste <br /> 0 0 PRC§42956-Registration/Decal in Vehicle I m / m <br /> Date <br /> 1 C 1 9 <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> I <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <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 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities - <br /> 8462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 1 In Compliance No Violations <br /> 0 0 14 CCR§1 <br /> 0 0 Other: § <br /> Comments <br /> ----------- <br /> Inspection Form Included: 0 Pone Number <br /> t rsS ture <br /> Comments Included: 0 Tth�oneiumber In p <br /> Business Rep's Signature S' 62081 <br /> It <br /> Correct:* Incorrect. <br /> INSTRUCTIONS ON BACK A. <br /> EWhite CoPY:CIWMB Yellow copy:operator Pink Co Y, <br />