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S6 a <br /> 6 9 0nspectj®nReport - <br /> Waste-Tirespection Report tVurnber <br /> c- State B California. p� p p� . <br /> CIWM8181(New04/04) Survey <br /> ve,y Fo m o Page <br /> I SI! llVVll 'V97 <br /> California Integrated Waste Management Board ar{.1 Y�+ tl y it G "b� - <br /> Part Ac <br /> -Survey -.--__-- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i I Inspection Type (Fill one) <br /> Site Suffix: U�, ( �r. r . Routines Re-inspection Referral <br /> -�� 0 OQ (D Observation <br /> Local If Referral, choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> r <br /> Business or Facility Name <br /> „Y,_ Inspected By <br /> Inspector <br /> a <br /> Physical Address <br /> eet _ <br /> Inspection DateF:) <br /> _i <br /> stala star %1P t=vde I Time In Time Out <br /> Business Re _ <br /> P Title --�Q AM w Q AM <br /> _ ... -- Q PM10 PM <br /> - —— <br /> i Operational Status TF ire TYPe Business Role IStorage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �`fire Count Whole/PTE —� ' <br /> - <br /> Active 0 Passenger Q Generator I Q Outdoor <br /> Latitude 0 Closed 0 Altered <br /> Grps Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> -_I 0 Planned--- 0 OTR0 Container <br /> g' - -- End-Use <br /> Lon etude � I <br /> - �-- <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> 'Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FENFORCEMENT STATUS — <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 'PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <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 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 (Requires/for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 14 CCR§18,460.2 Manifest System Requirements for Registered Waste Tire Haulers (DReferred/CIWMB Enforcement <br /> 0 0 14 CCR§1.8461-Manifest System Requirements for Waste Tire End-Use.Facilities <br /> 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> Q 0 Other: § <br /> Commentsr <br /> 1 <br /> , 1 <br /> i <br /> ,Inspection Form Included: 0l <br /> Comments Included - - - - <br /> _-- - Business Reps Signature Phone Number inspectors Signature _Phone Number <br /> -- -__ - - <br /> INSTRUCTIONS ON BACK Correct. Incorrect: X(,-) ( ; F. , s'0', t I °s <br /> 62081 <br /> � _ <br /> White Copy:CIWMB Yellow Copy'Operator Pink Copy:LEA <br />