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Waste Tire Sup �d� Inspection Report mspection Report Number <br /> lm _ State of California 1 _ 1 4 `� <br /> a; CIWM6181(New04/04) Survey Form - Page 1 _-J! 99 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: + ZI ;� C d Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local G,,- ` { , - If Referral,choose referral type(Fill one) <br /> Identifier: �.l.Vl �U-ti�u1� ���ti ' �'/ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name !!! Inspected By Inspector <br /> t,Yk.,_h 2>7y)& e v- 3 G <br /> Physical Address C?'/JC�jyp1�?lC7:J <br /> ss� <br /> (� tv CA Q �1� Inspection Date <br /> t-- Time In Time Out <br /> Business Res�••__p Title 0 AM ®AM <br /> A r 1'C�'l , `BMW( � O PM � QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> IS\ 0 Active 0 Passenger (a Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GpS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck i <br /> Longitude — 0 Planned ®OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 ® Other �� �` LZ;1}-i j 1/7 <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS 1 <br /> V A I HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 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 /> Inspection Form InCILlded: 0 <br /> Comments Included: 0 Ea� <br /> Business Rep's Signature Phone Number sp or's S ture Phone Number <br /> , � <br /> INSTRUCTIONS ON BACK CCorrect_0 Incorrect: I wl� E X A' e1411 21 31 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y:L ®62081 <br /> ■ <br />