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Waste Tire Sur-,9y & Inspection Report •nspection Report Number <br /> State of California ' -- ` ■ <br /> CIWMB 181(New 04/04) Survey Form - Page 1 t 1 01 0 7 3 0 <br /> California Integrated Waste Management Board J g �,_,_ _,._.,,___.0 _J <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile ,Inspec#ion Details <br /> TPID- L` � � � Inspection Type (Fill one) <br /> Site Suffix: / I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local (`1 �-- 6 If Referral,choose referral type(Fill one) <br /> Identifier: (/t , r1 ( V L., Yt i 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name `l Inspected B <br /> r _j P Y Inspector <br /> Physical Address <br /> Street t <br /> Inspection Date / t / [Zr-]/ <br /> i <br /> CityState ZIP Code Time In Time Out 0 AM <br /> Business Rep Title 0 AM <br /> ' DD0PM QPM <br /> r t Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)', <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> D (D Closed 0 Altered <br /> GPS Latitude m • � _ �� 0 Hauler 0 indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 7 .7 0 Planned 0 OTR 0 End Use Container <br /> , <br /> Business Type (Fill all lhat apply):, <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers, Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 In Compliance - No Violations <br /> 0 0 Other: <br /> Comments <br /> - � t _ Gf � ; � / �d _ {��'�� r i• G� f :C >� kms— !+,t !,�.1 a <br /> `�, .t t r>'; E"" 1�(� ( "; , _ '. _ �F• , . <br /> Inspection Form Included: 0; <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � 6201 <br /> a p �` <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEAH <br />