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- it; Waste Tire Su&_ y & Inspection Reporo Inspection Report Number ■ <br /> State of California ;§ sr"� r�r <br /> - CIWMB181(New 04/04) Survey Form - Page 1 _ t i <br /> California Integrated Waste Management Board - - - <br /> Part A__ Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j (} Inspection Type (Fill one) <br /> �_Site Suffix: L21 U•-_Llf Lclaj 0 Routine Q Re-inspection Q Referral 0 Observation <br />- Local- _ - - — -- - if Referral,choose referral type(Fill one) <br /> Identifier: SQr1 30Q{,Ut t Y� �.t�Ur -( O CHP 0 CIWMB Q Complaint O Educational Visit Q Other YI <br /> Business or Facility Name 1 <br /> Inspected By Inspector <br /> [=31 El [61 1-- <br /> __ sical Address <br /> Street Inspection Datecit <br /> L9 <br /> Bulsiness Rep C' Title 'tate ZIP Code Time In 0 AM Time Out _ 0 AM <br /> F7 0 PM OPM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ® Active Q Passenger Q Generator O Outdoor <br /> 0 0 <br /> _m III <br /> Closed Altered <br /> GPS Latitude Li_ O Inactive 0 Truck O <br /> Hauler Indoor <br /> 7T T-_ -- - T— <br /> Longitude - 0 Planned 0 OTR 0 End Use Q Container <br /> III Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government 0 Retreader L Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture 0 Shredder O Other <br /> Part B _ -- - ---- - - <br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of violation L Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m m <br /> 0 Q 14 CCR§18459.1 --Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 14 CCR 18459.3-Retention of Compre.hensive Trip Logs for 3 Years --- - - - <br /> OO 14 CCR§14 CCR 18461 -Manifest System Requirements for Wase Tire End-Use Facilities O <br /> 18460.2-'Manifest System Requirements for Registered Waste Tire Haulers Referred/CIWMB Enforcement I <br /> Q 0 14 CCR§18462-Manifest System Ret uirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> 10 O Other: § <br /> Comments \ <br /> tj` — -- <br /> Inspection Form Included: Q <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> • " I = - l- <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X G�, S , 1^ t. 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> III <br /> L <br />