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Waste Tire Su&y & Inspection Report*Inspection Report Number <br /> State of California <br /> �1tID��a CIWMB 181(New 04104) Survey Form - Page 1 - 1- 086994 <br /> California Integrated Waste Management Board -------- -- - - <br /> Part A- Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br />} Site Suffix: j t y gg <br /> _ _I L�� Q Routine Q Re-inspection Q Referral Q Observation <br /> Local W r If Referral,choose referral type(Fill one) <br /> Identifier: ( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address r - <br /> i _j <br /> Street <br /> it (. „ Inspection Date <br /> CityState Z! I Time In Time Out <br /> ' v P Code <br /> Business Rep Title L 11 O A O A <br /> l/ I� PM PM <br /> (� M M <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 /> 77 7' 0 Q Active Q Passenger Q Generator Q Outdoor , <br /> D Q Closed Q Altered <br /> GPS Latitude f , E ( I Q Hauler Q Indoor <br /> 90 Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> 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 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 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements i Date <br /> 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 /> -- <br /> Q O - <br /> 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 t 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 /> Inspection Form Included: Oi <br /> Comments Included: Q {` <br /> - , - <br /> Business Rep's;Signature Phone Nunalaer la�spector's Slgnatura�s, atr Phone Nu4nber 'f <br /> -. - - <br /> X ' � / `?f 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: V �a'I �' �. � � � � <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />