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.T . Waste Tire Surd & Inspection Report pection Report Number ■ <br /> State of California CIWM6181(New 04/04) Survey Form - Page 1 1 4 . 1 0 1 3 2 7 6 <br /> California Integrated Waste Management Board <br /> Pa�A�S��nre Y_ - <br /> Inspection Details BLUE OR BLACK INK PEN.,,, <br /> P <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: U �) n I I � a Routine Q Re-inspection Q Referral Q Observation <br /> Local - If Referral,choose referral type(Fill one) <br /> Identifier: �. �' ,J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> _o, Inspected By Inspector <br /> Physical/Addre s <br /> Street <br /> Inspection Date <br /> i Z ' .�.<. G ✓� f = « i <br /> City State ZIP Code Time In _ Time Out <br /> Business Rep Title O AM O AM <br /> ' I 0 PM 0 PM <br /> -- I Operational Status Tire Type Business Role ^r54orage Type <br /> (Fill one only) (Fill all that app,#1 (Fill all that apply) (Fill all that apply) <br /> (W, TE) <br /> j OTire Count Passen 'er OGenerator OOutdoorQActive <br /> O (6 Closed Q Altered <br /> GPS Latitude m • �_ � Q Hauler Q indoor <br /> __i0 Q Inactive Q Truck <br /> Longitude - Q Planned Q'OTR Q End-Use Q Container <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 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 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR 18459.3-Retention of Manifest Forms and Tire Tri Logs for 3 ears <br /> QQ § P 9 Y <br /> II <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 /> Inspection Form Included: QI <br /> Comments_Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ 4 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X ,°-;', I __ 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy LEA <br />