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Waste Tire SAey & Inspection Repor10L Inspection Report Number, ■ <br /> .^.�� � State of California =_ „ <br /> CIWMB181(New 04/04) Survey Form - Page 1 I I E a 1 `-- 7 1 <br /> California Integrated Waste Management Board — =- -- - - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPI <br /> - 19 i Q ! �_1_. <br /> Site Suffix: t J Routine 0 Re-inspection 0 Referral 0 Obse <br /> Site Inspection Type (Fill one) <br /> rvation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �- _1CA f) T% C t Cif 1 i l .,)t�t 1� -{� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or facility Name Inspected By Inspector <br /> Physical Address <br /> 5frcet Inspection Date �`� ETIE 10-1-51- J <br /> City t —' , ;tate ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> mile-, LLI <br /> 0 PM 0 PM <br /> - - <br /> _j_j <br /> --- __ <br /> Operational Status Tire Type Business Role Storage Type <br /> � (Fill one only) (Fill all that apply) (Fill all that apply)Y) (Fill all that apply):: <br /> Tire Count(Whole/PTE) I <br /> (3 Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude <br /> O 0 Closed 0 Altered O Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude j <br /> 0 End Use 0 Container <br /> Planned <br /> ustness Type (F1 all <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 6) Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A <br /> 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 /> 0 0 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 /> 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 i 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 /> - �� -a-----rte <br /> __.. , J <br /> I •.- ,r, --- '1--'.�.�. _;<;._-.�; i t.� _._�_ Y_ ._.-Y�'.f�t' �.i� .�",:i' -�""i(.. t.�/14 <br /> k-' _ _.t';•,l',�-Y. _i`'s I['; _ ,Y' i t tY.= f A 1-uf)f� <br /> Inspection Form Included: 0., <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> - - _- <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X Lj,',_ � �,; ,���, ���� 1 <br /> 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />