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Waste Tire SuWy & Inspection Repor*spection Report Number ■ <br /> y3 State of California <br /> s¢y�ad CIWM8181(New 04/04) Survey Form - Page 1 i - 0 13 10 4 <br /> California Integrated Waste Management Board -- - --- -- -- <br /> Part A Survey BLUE OR BLACK INK PEN <br /> u t' t "�'^� <br /> � <br /> TPID- I_ - Inspection Type (Fill one) <br /> Site Suffix: i r <br /> i Q Routine Q Re inspection Q Referral Q Observation <br /> Local w__�— 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 Inspected B Inspector <br /> _ -- <br /> Physical Address �j - / 0 T <br /> Street , 1FJ <br /> Inspection DateA <br /> Citv State ZIP Code Time Time Out _ <br /> Business Rep Title AM AM <br /> � L oPM H__1i OPM <br /> E-E <br /> I I -� Operational Status t„ Business Role � tM <br /> f� rtiarM e q75 W r <br /> Tire Count (Whole/PTE) (Fill one only) y (1 � <br /> (Fill all that apply) <br /> (8 Active r � ® Generator <br /> Lattu ���✓w: «fy'1�ra��gj�ytf„�✓aii��b ta�i Q HaulerGPS 0Q Closed <br /> Q <br /> r <br /> I <br /> Inactive i, � r� y �rft r tytu�r fiyGMYy irA <br /> Longitude - Planned Q End-Use <br /> Q <br /> Susin,ess Type ��lli all that apply) ', Ell III <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 1 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _I <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 <br /> M / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> § Y q <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> O Q Other: § _ " -- <br /> Comments <br /> Inspection Form Included: Q i <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 ;x;�A M P l <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />