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Ins <br /> ° Waste Tire S! ey & Inspection Repo Inspection Report Number <br /> ■ S State of California 1 1 1108440 <br /> CIWMB181(New04/04) Survey Form Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Bsiness <br /> T Profiler "t Inspection Details <br /> u ': <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: — (S Routine Q Re-inspection O Referral O Observation <br /> Local mm If Referral,choose referral type(Fill one) <br /> Identifier: ,Qr�" (;1 fl i 1U dQ CHP Q CIWMB Q Complaint Q Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> i <br /> Physical AddressL� toll I <br /> Street Inspection Date <br /> City .State ZIP Code {Time In Time Out _ <br /> Business Rep Title OAM O PM J� O AM <br /> t1F_7� <br /> ® PM <br /> I ��rl <br /> .._.�_ _ <br /> Operational Status Tire Type -� Business Role <br /> (Fill one only) (Fill all that apply) (Fill all that apply) <br /> 00 Q Active Q Passenger Q Generator 0 Outdoor <br /> Hauler Indoor ^' <br /> rr inactive Truck <br /> Latitude I I I O Q Closed Q Altered ' 1 I <br /> GP$ � Inac � O <br /> 0 <br /> J Container <br /> Longitude O End-Use <br /> Planned O OTR <br /> Business Type (Fill all#ha#ap' <br /> Q New Tire Dealer Q Auto Repair Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture 0 Shredder Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Yr?♦ <br /> 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 O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 14 CCR 18459.1 -Tire Program ID Number from CIWMB m Ell m <br /> Q Q § 9 <br /> O O 1 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 /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> O O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> O 10 Other: § __...._.... ..__.-. - <br /> y <br /> Comments } I <br /> Inspection Form Included: QI <br /> Comments Included: (J <br /> Business Rep's Signature Phone Number Inspector's Signature ........ Phone Number <br /> .� <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � \/ !_ �.": :N E t 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />