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0 Waste Tire Suy & Inspection Rep or Report Number ■ <br /> State of Survey Form - Page 1 i - �+ 8 <br /> CIWMBB181(New 04/04) <br /> California Integrated Waste Management Board _. <br /> Part A- Survey___ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Lc—) <br /> 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local f-- If Referral,choose referral type(Fill one) <br /> Identifier: :; 7, r 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Phys cal Address <br /> Street <br /> ' Inspection Date <br /> city Time In Time Out <br /> City State ZIP Code __. _ <br /> Business Rep Title O0 AM 0 AM <br /> PM � ' 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> p� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> Active 0 Passenger )Generator 0 Outdoor <br /> GPS Latitude m • 0 0 Closed 0 Altered O 0 <br /> Hauler Indoor <br /> ��O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR End Use 0 Container <br /> �@ New Tire Dealer 0 Auto Repair 0 Trucking Fleet -0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <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 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 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 /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred i CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 (D 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments t <br /> ,.1.1 9=4' �:.� -- -T w-��i,�•...� �� it c: --( �;.j .�-i��C.•r' / ---a�� G•;a'� ':n�'?':. <br /> ('�".`?'�'ri t.V-•_., ;•..(� -.j�� ...3r' ��/-""'S J(('��A tX'-� L."..����G'/` ��/'�, �i—'"I'V•- I� <br /> L. �� r <br /> Inspection Form Included: 0', <br /> Comments Included: O _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: Ik I 3� 62081 <br /> F r. ;s <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />