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Waste Tire Si ey & Inspection Repo <br /> Inspection Repo'rt�Vumber <br /> Fi186" State of California - <br /> iGli•:'S CIWMB181'(New04/04) Survey Form - Page 1 11 . - 1088427 <br /> California Integrated Waste Management Board <br /> Part A- SurveyBLUE OR BLACK INK PEN. <br /> Business Profile Inspection Details <br /> TPID- )) —y Inspection Type (Fill one) <br /> Site Suffix: 0 - X Routine Q Re-ihspection Q Referral Q Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: � � ()Ci q ��. C k Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t� <br /> Inspected By Inspector <br /> so <br /> Physical Address -�� - <br /> Vj <br /> Street (U !. <br /> I 7 `� 64Ins <br /> � V { pection Date <br /> I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title �- O AM Q AM <br /> /V � ..��/ t (t . 3 / QPM � ' � � PM <br /> 1C ! t.S ('{m !v� t ro I �h _ <br /> 11 1 Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) � � � f (Fill one only) (Fill all.that apply) (Fill all that apply) (Fill all that apply) <br /> j Q Active . Passenger ® Generator Outdoor <br /> m <br /> 0 -1 Q Closed Q Altered <br /> GPS Latitude L L J I a Hauler Q Indoor <br /> O i Q Inactive, Truck <br /> Longitude + Q Planned � OTR Q End-Use Container <br /> � <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel. <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station d Hauler Q Agriculture Q Shredder Q Other <br /> r <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q I Q I PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q i Q 14 CCR§'18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days / (Required for NOV or EXT) <br /> f <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q ! Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement . <br /> i <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _____-_____-,__.-....... <br /> Q ', Q 14(CR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> Q I Q Other: § <br /> 1k11Comments 110 l <br /> 'fi <br /> >.tL - ifr_ rrA� 6J� <br /> V( 4^�C' E tyl Cl✓l t 5 ✓''Y'r a r ({t 'i�.l �`� �t,+� L.t <br /> ilk <br /> Inspection Form Included: Q k <br /> 1 <br /> Comments Included: <br /> Business Rep's Signature_ Phone Number Insp ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK ! Correct:* Incorrect ,p _; , 2 3 62081 <br /> - - --- — <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />