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Waste Tire Spey & Inspection Re OI Inspection Report Number <br /> Lw Eu State of California p I 9 _,� �- 9 � 0- <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I s t� <br /> California Integrated Waste Management Board = _ <br /> Part A- survey6 F - BLUE OR BLACK INK PEN <br /> 7Suffi <br /> d Inspection Type (Fill one) <br /> ,® Routine Q Re-inspection Q Referral Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: J�� �C1 cl c-�UI i'1 C U u `A T_ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> Physical-Ad dress <br /> To I� <br /> L IIA ttaf7 �.Uf—c3 <br /> 21-9-9-L_11 - <br /> Street p J_o L6J <br /> 1 /^ [J Inspection Date <br /> L `__'� UIC�„ .__� __.__-_____ r��-_:� Time In Time Out <br /> City ,State ?ifi Code I- Out <br /> Business Rep Title 0 AM 0 AM <br /> .__� O PM – _� C Q PM <br /> Taer_m>, ��..e�1�[_ �_,_ _ray Operational Status Tire Type Business Role ,St geTypo. <br /> (Fill one only) (Fill all that apply); (Fill all that apply) all that apply)1 <br /> m <br /> i <br /> Active Q Passe <br /> Generator outdoor <br /> Latitude F �– '0 Q Closed Q Altered <br /> GPS ���__.. _._�__ _ Q Hauleriildoor <br /> Q Inactive Q Truck <br /> Longitude Q Planned Q OTR <br /> – Q End-Use Q Container <br /> JBusiness Type (Fill all 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 IS 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Notice Of Violation Q Extension <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 III / I]] / 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 (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive 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 /> 14 CCR 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q � Q § Y q <br /> Q Q Other: § <br /> Comments <br /> (-101 (7 1.0 i- <br /> iaa clg <br /> �C 0 t ) c� O tAJ__Va 1TNL <br /> --- <br /> Inspection Form Included: <br /> p Q <br /> Comments Included: Q <br /> Business Reps Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X �Xj,a,�W P 1.1-E !1213. 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA = ® ■ <br />