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:. Waste Tire Su my & Inspection Reports Inspection Report Number <br /> 3• State of California <br /> CIWMB 181(New 04/04) Survey Form Page 1 I1 - 1088203 <br /> California Integrated Waste Management Board Y - J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: I ' 17 3 I Z. 5 I Z LCE) _ I® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local1 If Referral,choose referral type(Fill one) <br /> Identifier: �!1 rl SO cl�tt 1 n C-O Lt n 1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> . t-on moodhavinj i i <br /> Physical Address I� KI I`-�),an <br /> �i 3 S E. Fre.n ch Ca+�a Rd . i - <br /> si,ee/ <br /> Inspection Date O a <br /> i Tr 9-y)cb Carpo CR 15 Z31 1 <br /> State ZIP Code Time In Time Out <br /> Business Rep Title O AM �— AM <br /> 11 I ' � PM � PM <br /> 71 R G�G I G e ri er 1 �-A f. <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 6 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude [T] 0 Hauler 0 Indoor <br /> _ 0 0 Inactive 0 Truck <br /> Longitude — I 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Q 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 ® Other <br /> Lan 6_s_c Q_ }n f_-M t �Ir <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 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-ganifest System Requirements for Tire Dealers or Waste Tire Generators 0 in Compliance - No Violations <br /> 0 0 Other: <br /> Comments <br /> Rot*tn- r-ne J. da�z__ -t I I _�czc, nod• <br /> A ,,ratroX . C.1 ,-,ed —FIrts s�o-ecb cn--,& • FOCIlli'y + PIcol) <br /> " re�'lar ociske e 4,rYeooyol � --k-)rt S r✓lo 1- r <br /> � <br /> rc nn n'�. a 1 e <br /> � I;rgnrlt�n —Tire_ <br /> Inspection Form Included. <br /> Comments Included: <br /> Business Rep's Signature Phone Number 1 ctor's Signatt <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 7l _MIPILI�T' 1112131 <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />