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..... ... ..... <br /> ---------- <br /> a-i- <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California 1140781 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board survey Form - Page 1 <br /> tA- Survey BLUE OR BLACK INKPEN, <br /> siness Profile Inspection Details <br /> TPID- l Inspection Type (Fill one) <br /> Site Suffix: 1 CQ 3 O 1 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Jo eAj it 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business-orFacilityName <br /> Inspected By Inspector <br /> Physical AAddress 3 I (, s�, <br /> Inspection Date <br /> cA Time In Time Out 111 <br /> Business Rep Title I 0 0 AM l C 0 AM <br /> 0 PM 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> PS Latitude 0 10 Closed 0 Altered 0 Hau 0 Indoor <br /> G 0 0 inactive 0 Tru, <br /> 'I (.vrl <br /> Longitude0 Planned 0 OTR <br /> 0 End-Use 0 Container <br /> --isiness 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 /> U 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 c9_ <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 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 O -- - — -- <br /> 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 1 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 1 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators • in compliance No Violations <br /> Other: § <br /> Comments <br /> ,inspection Form Included: 01 <br /> c <br /> Comments Included:*._ - �&*( <br /> Business Rep's Signature Phone Number Inspleco�'sSignature____ _�).ne Number <br /> 712131 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: x KT:_m_1_P Ft-TE <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />