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® Waste Tire SL y & Inspection Reporo Inspection Report Number ■ <br /> rs <br /> State of California - -! <br /> CIWMB 181(New 04/04) Survey Form - Page 1 ;�..- -. .,. „L { �' .:. <br /> California Integrated Waste Management Board ' � . <br /> Part A Survey BLUE OR BLACK INK PEN <br /> inspection Detalls <br /> } TPID- Inspection Type (Fill one) <br /> Site Suffix: i s_�_ � ��j f } Q 1 Routine 0 Re-inspection 0 Referral Observation x <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier:. �S <br /> 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 Address �' '— 2 <br /> 9 <br /> Street <br /> Inspection Date <br /> RZ <br /> S(ate zip Code Time In Time Out <br /> 0 PM <br /> Business Rep Title - 0 AM -- Q AM <br /> PM <br /> 1 rt Operational Status Tire hype? "Fusiness Role Storage Type <br /> (Fill one only) (Fill all that apply); (Fill all that apply) (Fill all that apply)li <br /> m ZOO <br /> ® Active Q Passenger Generator Q Outdoor <br /> GPS LatitQ Closed Q <br /> Altered <br /> Q Hauler Q <br /> indoor <br /> ude ]L-1-1 -LLe�4T _ inactive O <br /> Longitude QPlanned QOTRQ End-Use Q <br /> Container <br /> Business Type (Fill all that apply) <br /> 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 /> Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B <br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB 11:1 /m IE <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 /> - -- <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 /> 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § In Compliance - No Violations <br /> Comments p� <br /> Ao1](A <br /> Inspection Form included: Q; <br /> Comments Included: Q <br /> Business Rep's Signature Phone_ Number In.§peetor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X N EA ,� j P L E Po <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />