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Waste Tire Sulay & Inspection Reports Inspection Report Number <br /> State of California <br /> CIWM6181(New 04/04) Survey Form - Page 1 I - 1141249 <br /> California Integrated Waste Management Board ... .._.._ _. -__-. -._... <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details1.MEN <br /> TPID_ � Inspection Type (Fill one) <br /> ��Site Suffix: � 1 l7j Q Q Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: + dc Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> . ......L .:._... �.r..1 Com. : COY ....... ...._.. . � "...... . .....; <br /> j ; <br /> ,hee, I r 2 <br /> ( Inspection Date <br /> B;r, Sfatet O er'e Time In Time Out <br /> usmess Rep Title 0 AM ( � O AM <br /> LJ <br /> 1 ® PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill aII that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> r I <br /> Q Active Passenger Q Generator Q Outdoor <br /> , TO Q Closed Q Ailerecl <br /> PS <br /> GLatitude ; Q Hauler 0 indoor <br /> _...._.,. Q Inactive Q "truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> usiness;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 <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> — - ---- --- --- --- - --- - -- - --- - - -- Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 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 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 /> Q Q Other: <br /> Comments <br /> r <br /> Inspection Form Included: DI ' 1 <br /> Comments Includcd: 0 <br /> Business Reps Signature - Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 incorrect:X p 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />