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■ t Waste Tire Suiy & Inspection Repo Inspection Report Number` <br /> F55 State of California 1 7 ■ <br /> i55 C1WMB 181(New 04/04) Survey Form - Page 1 - 1 5 . 1 0 7 9 1 .; l <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1` Inspection Type (Fill one) <br /> Site Suffix: 'd (5 Routine Q Re-inspection 0 Referral Q Observation <br /> Local / i If Referral,choose referralAype(Fill on <br /> Identifier: L /, «)� �' / j ,. Q CHP Q CIWMB o Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address EEI '� <br /> Street ( <br /> Inspection <br /> -� ection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep tt Title 0 AM 0 AM <br /> m m Q PM m 0 PM <br /> Operational Status Tire Type .Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> U (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> , <br /> O Active Q Passenger O Generator O Outdoor <br /> O O Closed 0 Altered <br /> GPS Latitude m - IT] Q Hauler 0 Indoor <br /> Q 0 Inactive 0 Truck <br /> Longitude - O Planned 0 OTR O End-Use Q Container <br /> -- <br /> ---------------- <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler o Tire Derived Fuel <br /> � I <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Service Station Hauler 0 Agriculture 0 Shredder Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility _ENFORCEMENT STATUS <br /> V A HAULING AND MANWEST REQUIREMENTS <br /> O Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler.Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> O Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> O ' Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (aIn Compliance - No Violations <br /> 0 O Other: § _ <br /> Comments <br /> ---- �'• l �_� 1!. Iii,:F_—���j _ `' 7 {tet. j�.l 1 v r '.a C t�t � 1 `�.��) ��1 i it( i�� �l r t r'� ,/l �.F•: 1 i <br /> ' t I .�.._S'�. ~r � �C.."� (/trE � r r�`II( C-''� � it �tGII"' C �!;' [ C �. �i t:( ��� �t t f• t � d <br /> slr �'��L>( <br /> Inspection Form Included Q <br /> f r / <br /> Comments Included. Q <br /> Business Rep's Signature_ _ Phone N_ tuber Inspector's Signature _ Phone Number <br /> — - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: Erle .A,'11A P E ii 2 3 62081 <br /> _ <br /> ■ -. - . - , <br /> White Copy:CIWMB Yellow Copy:.Opera r Pink Copy:LEA ■ <br />