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---------------­ ------ <br /> ---­-----­- - <br /> Waste Tire Survey & Inspection Report 'Inspection Report Number <br /> State of California <br /> CIWMB181(New04/04) Survey Form - Page 1 1143531 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- <br /> Business Profile Inspection Details <br /> TPID- Inspection-7 - 0 1 Inspection Type (Fill one) <br /> aSite Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: 5, 0ffi �, Nj <br /> qCT -"Yq 60 U A 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> + <br /> Business or Facility Name Inspected By Inspector <br /> P h ys 1�ca)ACdkd-\re s's Y1 A,,6, <br /> 1010 (z - &fzkvv�- ume, <br /> Inspection Date 3 <br /> 7- fC4_C_kj CA cl_t5�4q Time In 0 AM Time Out 0 AM <br /> Business Rep Title 0 PM 6 0 PM <br /> rl <br /> Tire Type Business Role Storage Type%)e ` 60me,-Z- rAo-q!� <br /> Operational Status <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire ount (Whole/PTE) *Active ® Passenger Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 0 inactive 0 Truck 0 Hauler indoor <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q 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 /> 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 ENFORCEMENT STATUS <br /> S <br /> V A I 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 M M <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 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I 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 Compliance No Violations <br /> 0 0 Other: § -A <br /> Comments <br /> P, <br /> Inspection Form Included: 0 <br /> Comments Included: Al <br /> Business Rep's Signature Phone Number Ins dr' IgnaturY Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X :Ak �, [� XEA X14 P L 1 ' 2 3 <br /> ■ White Copy:COMB Yellow Copy:operator Pink Copy: <br />