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Waste Tire SAW & Inspection Repornspection Report Number ■ <br /> State of California I e r z �_ rm r) R <br /> CIWMB 181(New 04/04) D ! _ 1 I i _ = i} g = <br /> California Integrated Waste Management Board Survey Form — Page 1 - - - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile ° ", p - <br /> Ins ection Details <br /> Inspection Type (Fill one) <br /> Ste Suffix: 1 J, ! t/ t f Q (-.' t Q Routine Q Re-inspection Q Referral Q Observation <br /> Local- a / 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 /> l , <br /> Physical Address <br /> Street <br /> _�- <br /> } Inspection <br /> ; Date ! C <br /> Cih State ZIP Code Time In/ Time Out <br /> Business Rep Title AM O AM <br /> } i � �_ Q 0 P d � � Ij_ OPM <br /> -- OpI Status dire Type Business <br /> ole Storage Type <br /> (FI one only) ( apply) ( II all that apply) ( ialhat apply) <br /> v) <br /> Tire Count (Whole/PTE) Q Actgerive Q PassenQ Outdoor '. <br /> - 1 O Q Closed 0 Altered <br /> ,., <br /> GPS Latitude l- Q Hauler Q Indoor <br /> t-�--� CQ uQ Q Inactive Q Truck <br /> iQ <br /> 1 �T 1 F7 _7 �.._)_—.�.. O <br /> Longitude - Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all that apply) c rtly , <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 /> -,---- <br /> V i A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q E*tension <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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements 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 /> 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/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 /> 10 1 0 Other: § <br /> Comments <br />} ! J T i <br /> Inspection Form Included: Q <br /> Comments Included: Q - - - - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: �/ d A d"I i. I 1, 121 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />