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Waste Tire Survey & Inspection Report It . action Report Number ■ <br /> Cr: <br /> �!]1 State of California <br /> u>a ClwttB181(New 04/04) Survey Form - Page 1 I1 — 1141049 <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 39 '77 4 n Inspection Type (Fill one) <br /> Site Suffix: OC C� _l - C 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� �� ��� If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address (� y'�( A -e'MLpUV'_ <br /> II I C) e,3 . 16e-t4le►mavi ly • b�Ca©6 <br /> Inspection Date (� l <br /> Time In Time Out <br /> Business Rep \ Title O AM 1 O AM <br /> YKJ �fJ1J✓�,�1�1.� 5 : 0 a e PM --? � -� � PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passen er 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered A �A, <br /> GPS Latitude ®I Hauler 0 Indoor ' <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <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 ® Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FENFORCEMENT STATUS <br /> - --V -A-I HAULINGANDMANIFEST-REQUIREMENTS --- — _-- - <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB M / m / m <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXM <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q 1 0 Other: § <br /> Comments <br /> "_)elf _ - - <br /> i <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> usiness Re ure Phone Number Signature Phone Number <br /> _ <br /> INSTRUCTIONS N BACK Cor <br /> Incorrect: X �/l } A M L 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop :L ® ■ <br />