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Wast <br /> Ig Tire Sifley & Inspection Report Inspection Report Number <br /> i � <br /> ®m=�� State of California <br /> CIWM6181(New04/04) Survey Form - Page 1 - <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Surve <br /> Inspec „ <br /> . -M <br />� IIIIIIIIIIIIII <br /> TPID- I. <br /> Inspection Type (Fill one) <br /> Site Suffix: U I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ^ ri If Referral,choose referral type(Fill one) <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Identifier: - - - - - - - - - - <br /> Business or Facility Name fi Inspected By Inspector <br /> JA C <br /> kc( <br /> _ <br /> Physical Addre s J I t <br /> zk <br /> LStreet Inspection Date loll r f <br /> G. __—I� TimeOut <br /> C,- ------ —� State [IP Code Time In _ <br /> City Q AM [7—] Q AM <br /> Business Rep TitleQ PM (� O PM <br /> ) Y r` - - - - - - - <br /> - Operational Status Tire Type Business Role Storage ape <br /> apply) (Fill all that <br /> (Fill one only) (Fill all that apply) (Fill all that t apply) <br /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> 1� D 0 Closed 0 Altered <br /> Latitude [-- 1_--� •LT__ 0 Hauler 0 Indoor <br /> GPS _.D 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR <br /> 0 End-Use 0 Container <br /> Business Type (Fill all that apps , <br /> 0 New Tire Dealer 0 Auto Repair ® 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 /> � <br /> Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other O _ <br /> _ <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENFORCEMENT STATUS <br /> V � A .HAULING AND MANIFEST REQUIREMENTS --- 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956 Registration/Decal in Vehicle / / <br /> ' 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m m m <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> 0 1 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 1 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 0 Referred!CIWMB Enforcement <br /> 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities In Compliance No Violations <br /> 18462-Manifest System Requirements or re <br /> 0 1 0 � 14 CCR§ tfTiDealers or Waste Tire Generators O <br /> Y <br /> 0 0 Other: <br /> ts s <br /> Commen <br /> zo <br /> No <br /> '.9� <br /> Inspection Form Included: 0 <br /> Comments Included: 0Inspector's Signature Phone Number <br /> Business Reps Signature one b <br /> er <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X GfiA 111" <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />