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nspet;tion Report Number <br /> Waste Tire SuOy & Inspection Report <br /> W <br /> -� State of California �� �4 <br /> CIWMB181(New04/04i Survey Form - Page 1 g <br /> California Integrated Waste Management Board -- -- - -- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> itspection Details - - <br /> TPID- 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: r I f Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> ji - ----------- `3L I/ _ <br /> Physic-al Addr-ess <br /> Street , L Inspection Date ' (j ti <br /> _ <br /> City State ZIP Code Time In Time Out <br /> Business Rep TitleAM Q AM <br /> J L/ LE 0 P � LLJ 0 P <br /> �,L r ( - -- "I Operational Status f; Business RoMENEM <br /> le <br /> (Fill one only) `ly) (Fill all that apply) <br /> Q Active Q Generator <br /> Latitude O Q Closed <br /> GPS C O Hauler <br /> pp Q Inactive <br /> Longitude - Q Planned Q End-Use <br /> sfna�s'Type•� ►slftlr i �`td ,.r. <br /> Q New Tire Dealer Q„Auto Repair S 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 Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS - <br /> — -- -- R -- Q Notice Of Violation -Q Extension <br /> V �; A �HAULING AND MANIFEST REQUIREMENTS � <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 114 CCR§18459.1 -Tire Program ID Number from CIWMB” <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 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 /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violation& I <br /> O Q Other: § J <br /> Comments <br /> J � <br /> i <br /> inspection Form Included Qi <br /> Comments Included. Q <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> ` 62081 <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: � ,� � � IA'° F la-T, <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />