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Waste Tire Sufty & Inspection Reporoslnspection Report Number <br />�'°z State of California <br />�rnSurvey Form - Page 1 I - 1141162 <br />CIWMB 181 (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 - t Inspection Type (Fill one) <br />Site Suffix ; I l Routine 0 Re -inspection 0 Referral Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: i <br />O CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name Inspected B <br />/ p y Inspector <br />Physical Address E 1 t <br />'jek % df <br />I:_......_._.... i1— _..._....._..._.......... ....... ... <br />..__.._...... <br />Scree; �.y► �-��, r"--�-_ <br />Inspection Date 7 <br />(z 44 I�r CJ <br />State ZfF1 Code Time In "^ 'Time Out <br />Business Rep Title ,may L� [ Q AM h Q AM <br />.� <br />PM <br />....................... .._.__ 1 L._... ..,.. x.. 2. _._... ._......_ <br />Operational Status Tire Type Business Role Storage Type <br />The CCIUnt (l�VhcleiPTEj ? (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br />J 0 Active 0 Passenger 0 Generator 0 Outdoor <br />7GPS Latitude €O 0 Closed 0 Altered <br />€!! 0 Hauler 0 indoor <br />0 Inactive 07ltick <br />0 <br />Longitude I 1,.. 0 Planned 0 OTR 0 End Use 0 Container <br />Business Type ("Fill all that apply) h r <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 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 <br />V A HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § <br />_ <br />Comments <br />!tf�j - f s r <br />14 , V t ov,-4J cd e <br />t.. <br />. <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date LE / []:] <br />/ [I] <br />(Required for NOV or EXT) <br />0 Referred/CIWMB Enforcement <br />0 in Compliance No Violations <br />L"5 J so <br />bah U�(frP�s <br />r,yo6Y� �� yvfi�tl�� a 10 �f s5 C je V0l{�s If reV)�W,�C <br />Inspection Form Included: 0 <br />Comments Included: O <br />f3a3strses�s Rep's Signature Phone dumber <br />INSTRUCTIONS ON BACK Correct:® Incorrect: X <br />® White Copy: CIWMB Yellow Copy: Operator <br />Insp€;cior's Signature Phon^ ;d+. mb r <br />4 62081 <br />Pink Copy: LEA <br />