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Waste Tire SLfty & Inspection Repr Inspection Report Number ■ <br /> 1 State of California I [ 0 � }�+ .° <br /> CIWMB 181(New 04/04) Survey Form - Page 1 i n `' � t <br /> California Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> 6 <br /> Business Profile ;w r+ °d a �� / � 1�It' IrISpeCtfC1T1 beta 11, =---- --=-- — <br /> _ _ <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: t� �� Z ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: t)cen�M <3a C„p(-An-�u _ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address cl] <br /> 197L v <br /> Street <br /> r� ` <br /> Insp.e_c�tion Date 0._..��—}_ <br /> ._..l 1-9 <br /> Time InTime Out_ale <br /> f <br /> TitleAMBusiness Rep O AML [_ PM O <br /> PM <br /> O( ilerational Status , Business Role Storage Type <br /> Fl one only) (Fill all that aPlIY) (Fill all that apply) <br /> ' <br /> Q Active 0 Generator 0 Outdoor <br /> GPS Latitude _. �_.. �... _. ... - --- .. D Closed 0 Hauler 0 Indoor <br /> - _ 0 Inactive <br /> Longitude - u Planned `OTC; 0 End-Use 0 Container <br /> r <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 +C <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 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 <br /> O O <br /> 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB M / M / m <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 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 <br /> In Compliance - No Violations <br /> 0 0 Other: § - <br /> Comments <br /> 1 <br /> h CoX �)C-Q-n rlz�a TV .oe re -cam C'U c t,01_ <br /> XQ�tYa,< tin V-vo a i0n'`� 0r ctr�a c.c� CC n. <br /> - - - <br /> 77 <br /> Inspection Form Included. 0 <br /> Comments Included: 0 - f W <br /> Business Rep's Signature Phone Number Inspector's S-19nature <br /> ""�" �"°�' 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X r <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA _ ® ■ <br />