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Waste Tire Su j&y & Inspection Report0inspection Report Number ■ <br /> State of California , .> <br /> CIWM6181(New 04/04) Survey Form Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Busyness Profile; - Inspeetian'Detarts i! <br /> TPID- Inspection Type (Fill one) J <br /> Site Suffix: LJ <br /> lI II 16 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: t <br /> � --E-'-• Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> ...... LIJ dil <br /> Physical Address_ <br /> !t <br /> Street .-t�— <br /> Inspection Date a?_lo,A.-I <br /> City State ;,,ji Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> LE • --O PM 0 P <br /> Operational Status' fire Type '' '; Business Role <br /> (Fill one only) (Pili alt that apply) (Fill all that apply) <br /> r az <br /> t, Q Active Passenger` 11 Q Generator <br /> D Q Closed Q'Altered.' <br /> Latitude ELI <br /> i <br /> GPS Q Hauler Indoor <br /> O I* Inactive a'Truck <br /> Longitude Q End-Use Q Container <br /> II 99 Q Planned Q OTR, <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 Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityEN <br /> -ENFORCEMT STATUS <br /> EN - <br /> V ' A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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/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 <br /> Q In Compliance - No Violations <br /> O Q Other: § <br /> Comments <br /> Inspection Form Included: Q� <br /> Comments Included Q 1 Business Rep's Signature PhoneNumber -Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X "�, ,I L i 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />