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Waste Tire Su*y & Inspection Repor -Inspection Report Number t <br /> 7 '° State of California -� � <br /> n CIWM6181(New04/04) Survey Form - Page 1 ' <br /> California Integrated Waste Management Board <br /> Part A Survey BLUE OR BLACK INK PENT <br /> s Hessmuninaimni <br /> •mIlgagujis <br /> nspecton Details W �_ �_ ------ r. <br /> s ' <br /> TPID- / / Inspection Type (Fill one) <br /> Site Suffix: � - _ ! LL!J 0 Routine Q Re-inspection Q Referral Q Observation <br /> If Referral,choose referral type(Fill one) <br /> dentlifier: # l�; Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> L <br /> Business or Facility Name r Inspected By Inspector <br /> CRPh sical Address � � ! ( � - <br /> Street p <br /> Ins ection Date f' <br /> �� � Time In Time Out <br /> city <br /> State ZIP Code _.._- --._ � <br /> Y Business/Rep Title O PMO PM <br /> Operational Status I Tire Type FBusiness Role <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) <br /> Active Q Passenger Q Generator Q Outtlogr <br /> -} - -- � Q Closed Q Altered <br /> GPS Latitude - 9 Q Hauler Q Indoor <br /> �I O Q Inactive Q Truck <br /> I Q End-Use ( Ct7nttner N <br /> Longitude - i Q Planned Q OTR <br /> Business Type (Fill all thy, ` "' <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® 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 (5 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 /> Q' ice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. Co 'ance Deadline <br /> Q O § '�, <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date / 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 (Requked for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> — - — <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred l CIWNf6 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 lations <br /> Other: <br /> Comments <br /> i - <br /> - - ; 7 <br /> Inspection Form Included: 0, <br /> Comments Included: QI Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> - - 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X A�, \/__f f- X'M P 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />