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Waste Tire SuQey & Inspection Repor ,, Inspection Report Number <br /> State of California f <br /> CIWMB 181(New 04/04) Survey Form - Page 1 i ' 10 7 2 8 7 0- <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: ' 13171 11 3 J LO_[_I]- <br /> J 11 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local C1 If Referral,choose referral type(Fill one) <br /> Identifier: "~ _-Sc)G1 t 1('\ Ulti� 1 ' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address-� � q l <br /> Kr►`��"t rte L:,tCci�. I <br /> Street Q <br /> Inspection Date <br /> CA q 32c� <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title Q AM O AM <br /> opero'A l ahs m ' 0 PM O PM <br /> ----- <br /> Operational Status Tire Type Business Role Storage Type <br /> Fill one only) Fill all that apply) Fill all that apply) Fill all that a <br /> Tire Count (Whole/PTE) ( ( pp y) ( PP Y) ( apply) <br /> ,. - 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> m <br /> GPS Latitude 10 0 Closed 0 Altered <br /> 1 0 Hauler 0 Indoor <br /> D aInactive 0 Truck <br /> Longitude - k 0 End-Use 0 Container <br /> g I 0 Planned 0 OTR <br /> - .. <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 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 Other l h ,fir] McIE F L ,_ <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 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 fYl EC'� <br /> �( (( - -'�1t; (1-I c1tC Cl_- 70nk- A r')1'; ,t <br /> n.OJC I r, 7POC \ tarrn (AlN1201 C,(- +nrnlf`l— !�C O =��� W10 LOCI=-- i <br /> + rrC IAD Q A Q ha0 1\ i 1 C h-SJR' No v w1_aiIant: or rocea o� <br /> t371 2_13 — 01 <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> T" -- 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X i X,A h+, L[ETTL 1 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />