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09-18SO4e007 <br /> NA <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> LESgratedWasttate mla Survey Form - Page 1 I1 - 1108.427_ <br /> CIWMB 181(New 04/04) <br /> CaliforniaomlIntegrated Waste Management Board I—• <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Inspection Type (Fill one <br /> )TPID- <br /> Site Suff.: L0 ,_41II q] _[a_ L � ® Routine QRe-inspection Q Referral Q Observation <br /> Local \ If Referral,choose referral type(Fill one) <br /> Identifier: 1 1 JQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Bu iness or Facility Nam ' l Inspected By Inspector <br /> MM I , 1 <br /> Ph i�l Address � W <br /> ---- <br /> 5Ge <br /> Inspection Date i O � , I ;� i / I O • <br /> ` I � <br /> C,t r a 6"Code Time In Time Out <br /> Business Rep n Title OAM <br /> PM – – 1 ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count,(Whole/PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 /01 Active 0 Passenger 41l Generator Q Outdoor <br /> ! <br /> GPS Latitude O 40 Closed Q Altered ��n Q Hauler Q Indoor IN�� <br /> O Q Inactive Q Truck <br /> Longitude – Q Planned &,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 0 Other <br /> \ 1 <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 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 EX7) <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/C^IWMB 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 e In Compliance - No Violations <br /> Q Q Other: §,- — ------ --- <br /> Comments \ \ <br /> res S - <br /> Inspection Form Included: _' j� uI q �JQ <br /> Comments Included: q&AQureb <br /> Business RepPhone Number Ins cto?s Signature Phone Number <br /> INSTRUCTIONS ON BACK Cor ect: ncorreet: 62081 <br /> E x A hh P 'L E ; 1 '2 3 <br /> White Cop .CIW Yellow Copy.Operator Pink Copy:LEA <br />