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Waste Tire Sufi & Inspection Report"Spection Report Number <br />■ -�i1 State of California ■ <br />CIWMB 181 (New 04/04) Survey Form - Page 1 Il - 1143556 <br />California Integrated Waste Management Board <br />'art A - Survey BLUE OR BLACK INK PEN <br />Business Profile o I Inspection Details Li <br />Site Suffix: <br />Local S q n V 0� 1� 1 <br />Identifier: n (uLlflk <br />Business or Facility Name <br />m eA I s A ufo <br />Physical Address <br />'Si (3 cvz� 0 J-� ( A `15a06 <br />Business Rep + Title O AM <br />1 yl kv �vU n2r PM-- <br />— - - Operational Status Tire Type <br />Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) <br />3 If Active 0 Passenger. <br />GPS Latitude <br />O 0 Closed 0 Altered <br />, <br />O 0 inactive 0 Truck <br />Longitude - 0 Planned 0 OTR <br />Business Type (Fill all that apply) <br />Inspection Type (Fill one) <br />46 Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Inspected By Inspector <br />3 I- 1 0 1 Gln E5t„b <br />Inspection Date S / <br />Time In <br />0Q / 1 0 <br />Time Out <br />0 AM <br />' © O O PM <br />Business RoleStorage Type <br />(Fill all that apply) (Fill all that apply) <br />9 Generator (8 Outdoor <br />0 Hauler <br />0 End -Use <br />0 New Tire Dealer <br />0 Auto Repair <br />0 Trucking Fleet <br />0 Government <br />0 Retreader ® Dismantler <br />0 Used Tire Dealer <br />O Auto Body <br />0 Car Dealer <br />0 Collection <br />0 Crumb Rubber <br />0 Service Station <br />O Hauler <br />0 Agriculture <br />0 Shredder <br />0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V FA-] HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 -Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />010 <br />1 Other: § <br />\\ LL r( <br />Comments �li Y14-_ l 0 wlo_ 1 jt_ 1 i 1Sr-* yi (N1 ��T, i I n-\rA on <br />`1 (A a�i <br />t <br />nspection Form Included: Q'f%00 <br />Comments Included: 01V� - -- ----- -- <br />Business Rep's Signature _ Phone Number <br />INSTRUCTIONS ON BACK Correct:* incorrect: <br />■ White Copy: CIWMB Yellow Copy: Operator <br />0 Indoor <br />0 Container <br />0 Tire Derived Fuel <br />J ENFORCEMENT STATUS <br />f <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred/ CIWMB Enforcement <br />® In Compliance - No Violations <br />V <br />44--309 <br />one Number <br />62081 <br />