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Waste Tire Su & Ins ection Re or Inspection Report Number <br /> ' Y p p - --- <br /> ■ State of California ., € ' <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey -- -_ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r Inspection Type (Fill one) <br /> Site Suffix. ) rJ / Cr' Q^Q Q Routine Q Re-inspection Q Referral Q Observation <br /> Local _ + f If Referral,choose referral type(Fill one) <br /> Identifier. I t �:j�' I r ? ;1 t { Q Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ! ^Q Inspected By Inspector <br /> Physical Address �.,'� �tlti ;) • t.._.-___—T.: j l) l t / [T( i�J r t °` //.-------J <br /> - <br /> Street <br /> t <br /> � Inspection Date <br /> 9 .7 <br /> �� ; <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title ' OAM O AM <br /> 0 PM 0 PM <br /> L_ LW I Operational Status T Type 77 Business Role <br /> 11110111 pi a <br /> (Fill one only) (Fill all that apply) (Fill all that aPPIY) (Fill ali thbt app <br /> Tire Count(Whole/PTE) !' <br /> Y) <br /> �t ® Active Q Passenger Q Generator Q Outdoor <br /> QQ .[ p li <br /> Latitude Closed Q T] Q Hauler <br /> Q Indbpr 7 <br /> (_ <br /> Q Inactive Q Truck <br /> Q.�._,_Q—1 �____,_(_�7��- O <br /> Longitude — e OTR Q End-Use Q Co <br /> 0 Planned 0 ntainer <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 <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 Notice Of Violation Q Extension <br /> Q O 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 / Fll / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 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 I i <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q O 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 /> 1 - <br /> E ' <br /> Inspection Form Included: Q <br /> Comments Included: - - <br /> Q,Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ' �X1 117 <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> I <br />