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Waste .Tire Su y & Inspection Reportla <br /> nspectionReportNumber <br /> State of California � <br /> CIWMB 181(New 04104) Survey Form - Page 1 i '� 0 7 1 - <br /> California Integrated Waste Management Board <br /> Part A- Surve •` BLUE OR BLACK INK PEN <br /> r• `tail W " ,'Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l, L- LL (r Routine Q Re-inspection Q Referral Q Observation <br /> - -Local a If Referral,choose referral type(Fill one) <br /> Identifier: y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical AddressLA--jj <br /> _ <br /> I J '4 ; lr I <br /> Li11 `j . L_iU__"r C)r _l <br /> Street f (� Inspection Date <br /> o <br /> Cite State ZIP Coch Time In Time Out <br /> Business Rep Title O AM O AM <br /> l f � n ; <br /> LI-1L <br /> . O PM 0 P <br /> .11 <br /> , . <br /> S. Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> The Count (Whole/PTE) Q <br /> Active Q Passenger Q Generator Q Outdoor <br /> 0, Q Closed Q Altered <br /> GPS Latitude u Q Hauler Q Indoor <br /> - O Q Inactive Q Truck <br /> Longitude <br /> Q End-Use Q Container <br /> Planned <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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 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 -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 Q14 CCR§18459.3-Retention of Comprehensive Tri 14 CCR§18460.2-Manifest System Requirements for Logs for 3ears <br /> Q Q for Registered Waste Tire Haulers Q Referred I 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 /> t�fi t.•Lt t \t� --�-----� r � 1 ;1 _ � i,a'i"'.;%C 1;j �; t' �:•(t_ � _ - f r� 'l'' <br /> I / ! <br /> f <br /> Inspection Form Included: Q <br /> Comments Included: Q'i - - - - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> A _ _,' <br /> INSTRUCTIONS ON BACK Correct:* incorrect: a/ ": 1 P L L 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />