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nr Waste Tire"SUe & Ins action Re op- <br /> pec; Instion Report Number =' <br /> ■ - Y p p <br /> aiiHn. State of California ■ <br /> 6iRs.. CIWMB 181(New 04/04) - Survey Form - Page 1 I 1 - 1,086996 �{ - <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR3,BLACK INK PEN <br /> Business Profile ft.. I Inspection'Details <br /> TPID- / Inspection Type (Fill one) <br />}' Site Suffix: Ish 9I G 5� - G <br /> Q Routine (ip Re-inspection 0 Referral Q Observation <br /> t Local / If Referral,choose referral type(Fill one) <br /> Identifier: 5 t { C`(' L A \ l ( � ) � � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility.Name _ Inspected By Inspector - <br /> Physical Address I✓L_CJ / ���+ ( '� i �, C <br /> Street <br /> ���,� Inspection Date <br /> � � 1 G5 I Time In <br /> City State ZIP Code Time Out <br /> Business Rep Title ERI ' ®0 AM 0 AM <br /> PM ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> r <br /> Tire Count (Whole/PTE) <br /> ❑ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> % <br /> f f@ Active � Passenger ® Generator <br /> QQ Outdoor <br /> Latitude O 0 Closed 0 Altered "" <br /> GPS m • ® Hauler 0 Indoor <br /> 0 o Inactive 0 Truck <br /> Longitude - O Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair O Trucking Fleet O Government O Retreader 0 Dismantler O Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body. 0 Car Dealer 0 Collection O Crumb Rubber <br /> 0 Service Station Q Hauler 0 Agriculture 0 Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V ' —Ai HAULING AND MANIFEST REQUIREMENTS <br /> Q ( Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> O i O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 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 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q I 0 Other: § -------� <br /> Comments <br /> f <br /> Inspection Form Included: 0! <br /> Comments Included: - - <br /> Business Rep's Signature Phone Number• Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: X. j U E . , ti, �p 62081 <br /> ■ ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pini Co, y{L� <br />