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■ ° j Waste Tire Survey & Inspection Rep(,. t Inspection Report Number ■ <br /> :,. <br /> ➢�' State of California 11 - 1140646 <br /> CIWMB181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> A- Survey_ BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> TPID- i -7 <br /> / Ll <br /> Inspection Type (Fill one) <br /> Site Suffix: 4 5 95 -1t G ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalF� If Referral,choose referral type(Fill one) <br /> Identifier: ► - l�vl� r•-F,�t/i�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Q ''l�zry_ 6Dy4P(k'V' _ p <br /> Physical Address <br /> ���ZJ'� [.� . �--�1Ct,l�fir~' Ci.�r..r✓cf <br /> Z l Inspection Date <br /> , <br /> LL' ) `� <br /> Time In Time Out <br /> Business Rep Title Ll 0 AM e,— 0 AM <br /> ® PM `� QPM <br /> --- -- - -- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator ® Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck i <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> n.'siness Type (Fill all that apply) _ <br /> New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> lJ Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> QService Station QHauler QAgriculture QShredder 4P Other � vl Nt�!6i 4111no t <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 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 M / 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 (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 114 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 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: <br /> Comments Included: <br /> usiness ep's igna Phone Number t tor' I nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: X <br /> * Incorrect: i, ; 7C , P t_ ELf 3 <br /> M - -- -- .-. © ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />