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Inspection Report Number <br /> � <br /> "Waste Tire Sy & Inspection Repor p p <br /> ■ �u � . State of California <br /> 6�&jj CIWM6181(New04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board - - - <br /> Part A- Suryey _ _ BLUE OR BLACK INK PEN J <br /> BusinessProfile : , ,a Inspection Details <br /> TPID-� 1 � J Inspection Type (Fill one) <br />} Site Suffix. 5 ' �. �� �� Y_ Q Routine Q Re-inspection Q Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -` n 11 J O r) u\(1 C) Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ Inspected By Inspector <br /> L <br /> � <br /> Ph sical Address1 0__j� n <br /> Inspection Dateo <br /> City, spate ZWt6de Time In In Time Out <br /> Business Rep Title O AM O AM <br /> k�P_< �y D f: LLI L—L.- O PM ' O PM <br /> _ t__11 r� c <br /> "'- ,, Operational Status! Tire Type Business Role I Storage Type <br /> (Fill one only) (Fill all that apply); (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ' C) Generator Q Outdoor <br /> - --"- I--- - -D <br /> Q Closed Q Altere <br /> d <br /> Q Hauler Q indoor <br /> PSLatitude Inactive Q TruckQ Q End-Use Q ContainerLongitude <br /> F1 .0 Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 Other C?jA , i <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline ; <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 010 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O - --- ----- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 40 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments -t- L` oc�C+C ` -_ l o'f <br /> I -A <br /> Cern CWt) - __T_ . e (a rA_ A-9 C �`C C)n <br /> Inspection Form Included: Q' <br /> Comments Included: Q - - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> -- _ d 62081 <br /> I <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X V " �A M l l g <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />