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Waste Tire Surly & Inspection Report 'nspection Report Number <br /> State of California I f + _ �P A, �! ■ <br /> CIWMB181(New 04104) Survey Form - Page 1 I I ' W; <br /> California Integrated Waste Management Board -- - -- - 1 -- <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> fasptlan yleaa�s: W <br /> TPID- t rJ ` Inspection Type(Fill one) <br /> Site Suffix: I `� I I ! J �� J 4 Routine Q Re-inspection Q Referral Q Observation <br /> Local f _ —%+ if Referral,choose referral type(Fill one) <br /> Identifier: 91;( 1: /�( �f�� Q��4 ,. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or ty <br /> Facility Name J <br /> Inspected By Inspector <br /> Physical Address Lo <br /> /,'U` (ri `iyGk'� � �r <br /> Street DE <br /> Inspection Date L, <br /> - -- - <br /> city ' State LIP Code Time In Time Out T <br /> Business Rep Title AM O AM <br /> jj//nn / 1 O PM O PM <br /> _.L��i Y/'./ ..... �C/,lt�,f --�—� �*'"} r �y <br /> Operational Status tte, Yp�i 'Ia Business Roleype ,; <br /> (Fill one only) I)#ha(a(�Yly) (Fill all that apply) LFIII alt that apply}' <br /> Q Active °" Q Generator C)u#di�or <br /> GPS Latitude - _�4-- 0 ® Closed Q <br /> u Hauler <br /> Q Inactive <br /> Longitude – Q Planned Q End-Use <br /> Business Type (FiIfalLfihat"a <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 Q 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 bate 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 orEXM <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 /> 14 CCR§18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q - (6 In Compliance - No Violations <br /> Q Q (Other: § - <br /> Comments !' lI { !', 1 <br /> C - � -i � -J / � r C (/ i C j 7 ✓�� <br /> (-rr <br /> Ins,.p_ec,tionFwo, rm�� nciuded..wQw,�o. R <br /> £ <br /> Comments Included Q <br /> 13useps Si Phone <br /> Number rl mber_nature rv" <br /> n,W. <br /> INSTRUCTIONS ON BACK Correct:'10` Incorrect: X � ,: '' ;� 1 2 13 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />