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® r Waste Tire Su*,y & Inspection ReportInspection Report Number <br /> State of California I 1 11412 31 <br /> B <br /> CIWM181(New04/04) Survey Form - Page 1 - _ _...._. _- <br /> California Integrated Waste Management Board -- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- f //�^''� Inspection Type (Fill one) <br /> Site Suffix: <br /> L35 1 51 / Q Q� lJ i Routine Q Re-inspection Q Referral Q Observation <br /> Local -�y If Referral,choose referral type(Fill one) <br /> Identifier: `�� �(i64,L, �� �C'l'I i ` ` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ( )1 r�I dC!iJ t <br /> Q Q <br /> 3t6'64 Inspection Date <br /> v`�F1C�l Cct ti►l� _ _ <br /> C .�. Time In Time Out <br /> Ste ,r Coe! (. ._ <br /> 0 AM <br /> Business Rep Title AM ! • '<l C0 PM <br /> L J 0 PM <br /> „ ......., „ Operational Status dire Type Business Role Storage Type <br /> i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> ( @ Active 0 Passenger Q Generator Q C utdoar <br /> U411171 X <br /> _.._30 Q Closed Q Altaled <br /> �PS Latitude E Q Hauler 0 Indoor <br /> Q Inactive Q Truck <br /> Longitude - E Q End-Use Q Container <br /> Lon <br /> g Q Planned 0 O1 R <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Trucking Fleet Q Government O 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 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 O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q O 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 /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O in Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> - - tP jY-i�tP�-t� ,_> _tom v`1�' Cl <br /> lt� t7� 7 0 r rQ;Q, <br /> Inspection Form Included: Q r s <br /> Comments Included: Q C <br /> v <br /> Business Rep's ;tc,nature Phone N � <br /> Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® incorrect: X Ai IV <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA - <br />