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4Waste Tire Sy & Inspection Repor Inspection Report Number <br /> : � State of California - e 7 <br /> CIWMB181(New04/04) Survey Form - Page 1 - <br /> California Integrated Waste Management Board b <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> inspection Details <br /> - ._ -. . <br /> .Business Profile�, _ L_oU TPID- 1T� I O ' � � I � � IInspection Type (Fill one) <br /> Site Suffix: I © Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: _5a <br /> 76 u I CO, nA 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> I C-1MA C nasi T- Qu.,QMent I <br /> Ph s-ical Address <br /> 56oTj 1 L CGS <br /> I �;9O F,u6-1(an o <br /> Street <br /> Inspection DateFo <br /> F� / O 'l Q <br /> C <br /> F� - - - <br /> Crt E�� ���` l State ZIP Code I Time In Time Out <br /> Business Rep Title — O AM 0 AM <br /> 0 PM O 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 /> JT7 <br /> ® Active 0 Passenger Q Generator 0 Outdoor <br /> Latitude 0 Closed 0 Altered <br /> GPS L—� . I l I I 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - . I 0 Planned OTR 0 End-Use 0 Container' <br /> Business Type (Fill all that apply) r� <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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <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 FP / 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/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 /> Comments 0 w-,�Lac-A-w-a __+_9�(Aoux�,RJ_ cl cite <br /> hC�l`�t�J4C1�1�Q� nAetj : 'PCA C. j\�T��l���, W% - b-6+--- ;0 <br /> V=ZsT rn Q ►4e4 <br /> �,�-ala <br /> Inspection Form Included: 0' <br /> Comments Included: 0 -- - - <br /> Business Rep's Signature Phone Number In �rptor's Signatur <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X A�, X A M-IPILIEr It 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />