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`osaWaste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 1140625 <br /> California Integrated Waste Management Board <br /> -11:A-Survey BLUE-0 R_13 LACK INK PEN <br /> mess Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: LA q 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S(� u,11) CO U, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility al Name <br /> NInspected By Inspector <br /> Physicres <br /> ,�%I s y — 1 0 1 �W [_—C <br /> Jw Inspection bate 5 0 <br /> (Aq;—"v 6 Time In Time Out <br /> Business Rep Title rrll 0 AM0 AM <br /> 1A PM C) (a PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> '9 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Q Closed 0 AlleE), <br /> GPS Latitude 0 0 inactive 0 Tr, 0 Hauler 0 Indoor <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> Service Station 0 Hauler 0 Agriculture 0 Shredder S Other <br /> Ion <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -1 <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 /> 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 (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 014 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 0 in compliance - No Violations <br /> 0 0 Other: § <br /> Comments 11 I L <br /> I PejfurmeA 04 <br /> 0,0, (10 <br /> V,0 C, <br /> o+ cr n <br /> N �IF <br /> UA &_4rnu-00 f <br /> Inspection Form Included- O� <br /> 1� <br /> Comments Included: - - -- - <br /> 0 <br /> 1 Business Rep's Signature Phone Number 1npe r s�Sign.IuSre Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: F— 3 <br /> X XLA MI P <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />