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Waste Tore Surly & Inspection Reportionspection Report Number <br /> Sa State of California `� pyo ii <br /> ...... CIWMB181(New 04/04) Survey Form - Page 1 I i — 1141228 <br /> California Integrated Waste Management Board --- -- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> aA:r <br /> ass pLl <br /> — Inspection netailS �� _..,... .d; <br /> TPID- ' Inspection Type (Fill one) <br /> Site Suffix. _ (S 1 ; Routine Re ins ection Referral Observation <br /> = _ _. ,O O p O O <br /> C � U f l� <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other_ �- <br /> i <br /> Business or Facility Name Inspected By Inspector <br /> Physical 'Ad—dresss 0 i_ � '.. �! <br /> C ti JLI <br /> si ep n <br /> Inspection Date I ; �3 �0 10 <br /> , 9 <br /> ste'te ZIP Coo Time InTime Out <br /> Business Rep Title AMi O AM <br /> �>✓ 0 PM _I3 �� Q PM <br /> ct1e5 _ <br /> �. _. t _. -__ ._ . . __.___...._ <br /> Operational Status Tire Type Business Role Sforage Type <br /> 707 <br /> ®� ' `� I (Fill one only) (Pili all That 2Gpiy) (Fill all that apply) (rill all That apple) <br /> Tire 6ount (Whole/PTE) + <br /> 7 ' 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude I 0 Hauler 0 Indoor <br /> � ( i 0 Inactive 0 T ruck <br /> Longitude 9 0 Planned O OTR Lon I - 0 End-Use 0 Container <br /> — � � i <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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O-- --- 0 Notice Of Violation 0 Extension <br /> 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 /> M / M m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <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/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 Generator 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> . _ CCA"I h <br /> Inspection Form Included: 0 <br /> Comments Included: 0 `� - <br /> Business Rep's Signature Phone Nul�r,&aer Inspector's Signature r����� Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ; # � 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />