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Waste Tire SuMa & Inspection Report%spection Report Number <br /> �a�a State of California Survey Form - Page 1 1 3 - 1 0 13 2 7 5 <br /> �% CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board ---- ----- ---- <br /> Part A- Survey <br /> BLUE OR BLACK <br /> Business Profile ,., (mInspection Details <br /> . � � 'airs r •��� <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: (-+r L --' Q Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ; <br /> Inspected By Inspector <br /> - <br /> Physical Address - J_f <br /> r I I <br /> Street _ <br /> Inspection Date <br /> Cit State Z/P C.Ode Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> 7 <br /> O PM O PM <br /> t_ �_� _ ---------a t--- ---- - Operational Status Tire Type Business Role Storage Type <br /> AE <br /> (Fill one only) (Fill all thatapply), (Fill all that apply) (Fill all that apply) <br /> Tire Count (�fF hole/PTE) <br /> 7 Q Active Q Passenger Q Generator Q Outdoor <br /> 0 Truck f 0 Closed Q Truck <br /> red <br /> GPS Latitude <br /> i Q inactiveQ <br /> Tr Q Hauler Q Indoor <br /> O <br /> Longitude - �_1 . FTT�—�7 Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Sill ail that apply <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> Q Q ! 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB 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 Violations <br /> Other: § <br /> Comments �. <br /> Inspection Form Included: Q', <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X - <br /> Copy: <br /> ® White -_ ■ <br /> CIWMB Yellow Copy:Operator Pink Copy:LEA <br />