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Waste Tire Sur*y & Inspection ReportInspection Report Number ■ <br /> State of California 9 r} � "`° 6 <br /> CIWMB 181 New 04/04) Survey Form - Page 1 ; i= . 4 <br /> California Integrated Waste Management Board -- s <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ) 1 Inspection Type (Fill one) <br /> Site Suffix: f L{ `.? r Q Routine Q Re-inspection Q Referral Q Observation <br /> Local f If Referral,choose referral type(Fill one) <br /> Identifier: ' � ( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> ._.. <br /> Business or Facility Name rJ <br /> Inspected By Inspector <br /> 6�Physical Address <br /> Stree&jInspection Date <br /> C D '7oC 0 <br /> I � _ <br /> -- n Time Out 0 AM <br /> Business Re Title I <br /> Rep _. <br /> !'+ - ,State ,_/P Code Time <br /> OPM 0 P <br /> Operational Status Tire Type BUssRole Storage <br /> Tae <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all apply) (Fill alapply) <br /> ' Q Active Q Passenger Q Generator Q Outdoor <br /> 0 li Closed Q Altered <br /> Q Q <br /> GPS <br /> LatitudeEE - I i I I i <br /> Hauler Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - �~ 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 <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 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments �. ` <br /> is had lc V1 a1I`' o c <br /> wd <br /> Inspection Form Included: Q <br /> Comments Included. Q - - --- - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> __... - 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X A�, \/ f A 40. e' I,_ I <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />