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■ ' Inspection Report Number <br /> Waste Tire S�Jy & Inspection Repor <br /> F State of California I :7 ,1 '7 A <br /> CIWM6181(New 04/04) Survey Form - Page 1 t - <br /> Califormm <br /> a Integrated Waste Manageent Board - <br /> Business Profile <br /> BLUE OR BLACK INK PEN <br /> Inspection Details - - <br /> TPID- j nspection Type (Fill one) <br /> , 1 <br /> f Site Suffix: ' -J � �� ( Q Routine Q Re-inspection Q Referral Q Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address LJ tliz_ L, o rr-- <br /> Street <br /> - _ Inspection Date — <br /> I <br /> _I <br /> State Zlfu'Cr.)de Time InTime Out <br /> Business Re _ 0 AM <br /> p Title O PM .— � O PM <br /> Operational Status Tire Type Business Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)', <br /> Tire Count(Whole/PTE) Q <br /> Q Active Q Passenger' Q Generator Q Outdoor <br /> Closed Q Altered <br /> Latitude <br /> GPS E—E - �. ���� � Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 I <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 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 / FTI / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 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 Q Referred/CIWMB Enforcement <br /> Q 0 14 CCR§ 18462-Manifest System Req - <br /> 14 CCR 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q § y Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § — - <br /> Comments <br /> Inspection Form Included: Q' <br /> Comments Included: <br /> Q'Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X 2 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> I <br />