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® Waste Tire SuJ*y & Inspection Reports Inspection Report Number <br /> State of California <br /> CIWMB 181(New 04104) Survey p 11 — 1.J�1411 � 3 <br /> California Integrated Waste Management Board y Form - Page 1 -- --- . <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> '� ',ess Profile Inspection Details <br /> TPID- ( r Inspection Type (Fill one) <br /> Site Suffix: <br /> Q Routine Q Re-inspection Q Referral Q Observation <br /> Local _ y^ If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name : Inspected By Inspector <br /> Physical Address <br /> 1.... :.. _`..�. ':.._.._._.......` .. 5 �Y)....................... ... . ... .._................_.....-....... <br /> _..... <br /> Street Inspection Date <br /> S/<, e Out <br /> ,e ZIP iso 1<a <br /> Time In Time <br /> Business Rep Title ' AM / 0 AM <br /> J P 0 ' � O <br /> ¢� ,tet 0 M O PM <br /> _.. ........,.. !i.?1..,�..k.!) __�_� _....._ .__ Operational Status 'Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill ail that apply) <br /> m77 1';, Q Active Q Passenger Q Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> Latitude <br /> Q Hauler Q indoor <br /> TrtckQ Inactive Q <br /> o <br /> f Q End-Use Q Container <br /> Longitude – 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 Q Other IAC <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 — I 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 /> Q Q 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 Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 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 Q In Compliance - No Violations <br /> Q Q Other: § _ <br /> Comments <br /> r � <br /> Inspection Form included: J <br /> Comments Included: Q <br /> Business Reps Signature- Phone Number inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X >a M. (�'; � � 2 3i <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />