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Waste Tire SurvJW Inspection Report 1�ection Report Number ■ <br /> =a=-` State of California - 1088437 <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board - - <br /> Business Prof ley. "i _ - I Inspection-Details - BLUE OR BLACK INK PEN <br /> TPID- —) I Inspection Type (Fill one) <br /> Site Suffix: T' �} 8 �'` ' Q Routine Q Re-inspection Q Referral Q Observation <br /> Local _ / If Referral,choose referral type(Fill one) <br /> Identifier: LJaL (� � ( V�OQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> 6MCInspected By Inspector <br /> i ` j <br /> Physical jf5dress s � 5( I ! V ! <br /> Street <br /> 7rorw 04 953o4 I Inspection Date i � 5 <br /> O <br /> Time Citi State ZIP Code Time 1n � _ <br /> Business Rep Title J`} / 0 AM I O AM <br /> f LJ �L O PMD �^ Q PM <br /> of e (� TO ri -- - -- - -MITr ' <br /> r-I, Operational Status Tire Type Business Role i Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> ,L <br /> Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> ' <br /> Q InactiveQ <br /> Truck <br /> Longitude r7" e <br /> Q Planned Q OTR Q End Use Q Container <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 Q Q <br /> Notice Of Violation 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 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 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred i 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 /> Commentsc ,c <br /> Zr� f�&rn tOa <br /> `Kil.� `t �1/01 t, 6f lvu,r f (E- <br /> zq�' U P 5� >�' rf Y1 �. r "t,tflp G! ` <br /> ti , <br /> / <br /> fl C <br /> Inspection Form Included: Q, <br /> Business Rep's Signature, Phone Number Ins ector s Signature Comments Included: Q natur <br /> p' p ___ g Phone Number <br /> • - `S 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: - P; L I[ 1 2 ,_:i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />