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Waste Tire S & Ins Inspection Re ,ornspection Report Number <br /> WE, <br /> �u1 �]State of Californiarr 4CIWMB181(New04/04) Survey Form - Page 1. �. 4 - .1 0 .1. 0 7 0 3 <br /> California Integrated Waste Management Board <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- V I Inspection Type (Fill one) <br /> Site Suffix: Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) . <br /> Identifier,: ` ( qfxwi (') L 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name � - - - -- —- --- — <br /> lJ' Inspected By Inspector <br /> Physical Address ? C <br /> Street <br /> Inspection Date / lol / <br /> City_ State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> I _ ! r�/ r mm0PM <br /> ZIC V' <br /> ELIem OPM <br /> i Operational Status Tire Type Business Role Storage Type <br /> Tire CountWhole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( ) ' f ® Active Passenger Generator 0 Outdoor <br /> GPS Latitude <br /> O 0 Closed Altered <br /> m . <br /> 0 Hauler 0 Indoor 11'' <br /> 0 0 Inactive Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <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 /> 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 +(� <br /> Part Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <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 /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 14 CCR§18459:2.1 -Submittal of#Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3_Retention of Manifest,Forms and Tire Trip Logs for 3 years <br /> ----------- --- -... ._. ----.... ........-- <br /> 0 „; , `CR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 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 <br /> 0 0 Other: § Q In Compliance - No Violations <br /> Comments ��,,� /✓L ("s / rlArl V 0 <br /> Jfr C(�c '!'til 7Ile ClJ�i���r � t'.' -r,nz ��t✓ `��r<` <br /> VICt I L✓ air tl )d- znc <br /> kC.< ^ V r l <br /> Inspection Form Included: _ _7777 <br /> Comments Included: <br /> Business Signature Phone Number Ins ect 's Si natu a Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ( ) E 3�: .A ' ', P ;Lv, 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />