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Waste Tire Survey & Inspection Report InspecJ.V.�i�r�l .W <br /> ■ -��,�' State ofcallfornla P p <br /> CIWMB 181(New 04/04) 'Survey Form - Page 1 1 4 . 1 0794N, <br /> calltomla Int,911"d Waste Management Board <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile -inspection Details <br /> ` I s Inspection Type (Pili one) <br /> Site S <br /> Site Suffix: o J 6 3 L; 3 V ' ®Routine Q Re-inspection Q Referral O Observation <br /> LocalIf Referral,choose referral-type(Fill one) <br /> Identifier: ..� "6" C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> i <br /> I_Da 4 <br /> co ni S l�i <br /> t - WoY�CS I <br /> Physical Address U <br /> L <br /> - <br /> Street Inspection Date <br /> Si oct[iOr - —_.Gf _ S_SZ AS J <br /> City $tate Z1P GTode Time0 AM <br /> I <br /> n <br /> m Time Out <br /> Business Rep Title I I I OPM M'ED OPM <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 /> r Q Active Q Passenger Q Generator Q.Outdoor <br /> 10 Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> IL Q Truck <br /> Longitude - yjO ®Q Planned Q 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 Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler.and End-Use Facility ENFORCEMENT_STATUS - <br /> V A I 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 EXT) <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/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 10 1 Other: § <br /> Comments <br /> �O fjr.L Ca�_—CI.l_"isicn.L�i.�-7-ivS--Si'�c, r d2'e6• <br /> n__c •r mute—�r�.- <br /> Inspection Form Included:Q <br /> Comments Included:Q Business Rep's Signature Phone Number —nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: incorrect:NQ I& X A tM P 1L e ''2 3 62081 <br /> 1 ■ <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA <br />