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■ �^ Waste Tire S�y & Inspection Repo Inspection Report Number ■ <br /> c - <br /> rState of California n <br /> j €} .+ Ft 9 r rs <br /> CIWMB 181(New 04/04) Survey Form - Page 1 s <br /> California Integrated Waste Management Board - ' <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detais I y ,s M s ,", r` <br /> - _ - _ <br /> TPID- / + Inspection Type (Fill one) <br /> Site Suffix: ` 2-1 S IS 7 b �`" � � �_� � ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local - - - - If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street <br /> �tateca ZIP Code� Time Inaction Date <br /> city Time Out <br /> Business Rep Title <br /> 0 AM 1 Q AM <br /> LE QPM ._... 0 PM <br /> k _ _ <br /> Operational Status Tire Type I Business Role Storage Type <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> MINIM I M, I <br /> :a:.1L_.1 1— 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude 0 Closed 0 Altered <br /> GPS <br /> LJ <br /> __._� 0 Hauler Q Indoor <br /> Q Inactive 0 Truck <br /> 7 -70 End-Use 0 Container <br /> Longitude 0 Planned 0 OTR <br /> Business ryte,.,: lhali <br /> - <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> art - <br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ _,- <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> C7L K n•'� ��\�{ - -,� n4 ra >Lo.~���ttl "c,r ./ tP,��. — <br /> :Inspection Form Included: 0 <br /> s r <br /> I� <br /> Comments Included: <br /> I Business Rep's Signature Phone Number Inspector's Signature Phone Number i <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X A�, A P, l._ 1 <br /> i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />