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Waste Fire SuSby & Inspection Report• Inspection Report Number <br /> m ■ <br /> State of California <br /> �,h <br /> Cal Survey Form - Page 1 1 5 - 1 0 0 0 1 0 <br /> CIWMB 181 New 04/04, <br /> California Integrated Waste Management Board ..--.--- .-.- .--- - -- -.--..---� <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> ..-mar . . S@ �9 <br /> TPID- y� )r Inspection Type (Fill one) <br /> Site Suffix: r 0 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 /> j <br /> Physical Address i ' <br /> ,__ <br /> l j tti <br /> Street <br /> Inspection Date [E-, <br /> City State Zip Code Time In Time Out <br /> AM <br /> Business RepF ` Title AM <br /> O PM . � 0 PM <br /> Operational Status Tire Type r Business Role Storage Type <br /> TICe C011nt(Whole/PTE) , (Fill one only) (Fill all that appiy)I, (Fill all that apply) (Fill all that apply) <br /> .y 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> - O <br /> Latitude Q Closed-) 0 Altered <br /> GPS . ', 0 Hauler 0 Indoor <br /> LL��JJRude OAnactiv F 0 Truck <br /> j� O <br /> Lon - � I __� <br /> g� C) Planned 0 GTR 0 End-Use 0 Container '. <br /> Susiness 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 Cg1 llection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> , <br /> Part B - Inspection of Waste Tire DealerGenerator, Haul <br /> er and End-Use Facility . ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ----- 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 /> f <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 !i 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: 0' <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ <br /> ' -(--T-1 V 62081 <br /> INSTRUCTIONS ON BACK Correct: ncorrec <br /> It: X o 0.4 f_, <br /> _ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />