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.. <br /> .... ... .. <br /> ­_40 <br /> A <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> ■ <br /> State of California 11 - 1127894 <br /> CZMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Inspection Details <br /> Business Profile <br /> Inspection Type (Fill one <br /> TPID- 6 _7 C) 0 Observation <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral <br /> If Referral,choose referral type(Fill one) <br /> Local Co�_A& 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Identifier: SOS\ <br /> Business or Facility Name Inspected By Inspector <br /> A PDC, Avg 39 o 1 L vAT?,tK� <br /> Physical Address <br /> G <br /> Inspection Date c), <br /> cA q5205, Time In Time Out <br /> 0 AM 0 AM <br /> Business Rep Title i <br /> C) to PM a <br /> Operational Status Ti-re Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 0 Active Passenger Generator 0 Outdoor <br /> GPS Latitude 0 ® Closed 0 Altered 10 Hauler 10 indoor <br /> G 0 0 inactive 0 Truck 0 End-Use 0 Container <br /> Longitude 0 Planned 0 OTR <br /> Business Type (Fill all that apply) 0 Retr ader 0 Dismantler 0 Tire Derived Fuel <br /> 0 New Tire Dealer (D Auto Repair 0 Trucking Fleet 0 Government <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 /> I <br /> HAULING- . __AND-MANIFEST., REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> T0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 <br /> 0 0 PRC§42956-Registration/Decal in Vehicle m / m / m <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> '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 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 Requirements <br /> 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 in Compliance - No Violations <br /> 0 0 Other § <br /> CommentsA <br /> rJtne' on <br /> Ci <br /> Inspection Form Included: 0 <br /> �U�7� <br /> Comments Included: 0 ns ec r' S tune Phone Number <br /> Business Rep's Signature Phone Number <br /> 62081 <br /> ti2 <br /> INSTRUCTIONS ON BACK i Correct:* incorrect: A <br /> ■ White copy:CIWMB ■ <br /> Yellow Copy:operator ns <br /> opy:LQA4 <br /> (, T1 <br />