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Waste Tire Suay & inspection Report lonspection Report Number. ■ <br /> Ca State of California 1 <br /> CIWM6181(New 04/04) Survey Form - Page 1 I 1 - 1141305 <br /> lifornia Integrated Waste Management Board -.. -.-- --- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> BusinessProfile Inspection DetaHl£ <br /> TPID_ 3 L Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> ..._ <br /> Business or Facility Name Inspected By Inspector <br /> Physical AddressE3A <br /> lJ <br /> l ..........................._............. <br /> - <br /> Street <br /> r <br /> Inspection Date E 61 <br /> - Iat<- iF'Cclw Time In Time Out <br /> Business Rep Title AM AM <br /> 0 PM 0 PM <br /> x)y �j <br /> 4- �/_... 1 ......... ._a _ �. ...... 1 _ ........ . ......i <br /> Operational Status Tire Type Business Role Storage Type <br /> . (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that a(ply) <br /> Tire Count(Whole/PTE) <br /> ' .. 1 <br /> Q Active Q Passenger Q Generator 0 Outdoor <br /> Latitude <br /> 0 Q Closed Q Altered <br /> GPS 9 1 I � Q Hauler Q indoor <br /> ----- — � ' ( _Q_,• : Q Inactive Q Truck <br /> r O <br /> Longitude - ? Q Planned Q Ol R 0 End-Use Q Container <br /> Business Type (Fill all that apply 1 ' <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 A HAULING AND MANIFEST REQUIREMENTS <br /> -- Q Notice Of Violation Q Extension <br /> Q Q-- <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Requires!for NOV or EXT) <br /> Q 0 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 0 Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 (Other: § <br /> Comments riry <br /> ( � <br /> AC <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:0 Incorrect: X �/ t X A e�'t� 1 2 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />