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t Waste Tire uA - j & MspecUon Report ispection Report Number <br /> ,.a State B California g� 3 1 - <br /> , � CIWM6181(New 04/04) Survey Fors — Page 1 tJi'd}I 11fI1 ,i`i�? 't"Ij <br /> California Integrated Waste Management Board 1i' Form 8 to �n _ - -^ <br /> —' <br /> Suryey --- - -- - --- ----- ---- - - BLUE OR BLACK INK PERI <br /> Part A <br /> Business Profile ', �Inspection Details <br /> TPID"� / Inspection Type (Fill one) <br /> Site Suffix: <br /> 0 Routine Q Re-inspectionReferral -Observation <br /> Local �,,:-- 0 0 <br /> If Referral,choose referral type(Fill one) <br /> Identifier: - <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - — — - -- <br /> r Inspected By Inspector <br /> Physical Address ) _ — <br /> � - <br /> ._ <br /> Sireel <br /> ——�--" I� <br /> Inspection Date tr . r <br /> J__ <br /> City v state LJr"Codh I Time In Time Out <br /> Business Rep O AM <br /> Title T j Q AM <br /> I . � <br /> Q PM QPM <br /> O Fill <br /> one onl Tire Type Business Role Storage Type <br /> ---- - - rational Status <br /> Tire Count (Whole/PTE) ( y) (Fill all that apply) (Fill all that apply) I (Fill all that apply) <br /> _ 9 O (:D Active 0 Passenger � Generator Outdoor <br /> �� Latitude <br /> i Closed Altered <br /> GL ! <br /> _ ' I J I l j Q Hauler 0 Indoor <br /> = r --I�-10 0 Inactive I 0 Truck <br /> Longitude - I 0 Planned 0 OTR End-Use 1 0 Container <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 /> Q Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service StaElon 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Mauler and End-Use Facility ENFORCEMIENT STATUS --- <br /> ---------- <br /> Q/ j A HAULING AND MIANWEST REQUIREMENTS — h <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport Tires <br /> Notice Of Violation 0 Ext <br /> of ension <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 / [E / 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 14 CCR§ 1846.0.2-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 /> § <br /> 0 In Compliance - No Violations <br /> 0 0 Other: <br /> Comments 1 <br /> Inspection Form Included Di <br /> Comments included <br /> _-_- — DBusiness Rep's Signature <br /> — = Phone-N—umb=er Inspec-_or's <br /> Signature_ - Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK ; Correct: � Incorrect. l <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />