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Waste Tire SAVey & Inspection Repo* Inspection Report Number ■ <br /> .: State of California E r+ a ,��, �7 <br /> y CIWM6181(New 04/04) Survey Form - Page 1 _ f <br /> E t ' `•4 <br /> California Integrated Waste Management Board '�.__.. <br /> Business ess P ofiley ' ' " '`"''` ` ' " `"" Inspection Details BLUE OR BLACK INK PEN <br /> Bsi <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I [-aoRoutine Q Re-inspection Q Referral Q Observation <br /> 1 U n <br /> If Referral,choose referral type(Fill one) <br /> Q CHP Q CIWMB Q Complaint <br /> Q Educational Visit Q Other. <br /> Identifier: o � <br /> Business or Facility Name <br /> Inspected.By Inspector <br /> o��.rs _ <br /> Physical Address - -- —� � C-3 1 _ ' <br /> Street <br /> Inspection Date <br /> Lgji <br /> q'S 7-LA 0 F0 <br /> ;,7, State Z/fes C de Time In Time Out 0 AM <br /> _ <br /> Business Rep <br /> Title OO PM .__ O PM t, <br /> (Fill one only)lStatus (Fill Type <br /> apply) (Fill all that apply) (Filo)allthat T apply) <br /> FI <br /> ness <br /> Tire Count (Whole/PTE) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> SPS Latitude <br /> i ® Closed Q Altered <br /> LatQ Hauler Q Indoor <br /> p yy i jjO <br /> Q Inactive Q Truck <br /> Longitude — T{�F o Q Planned Q OTR 1 Q End-Use Q Container <br /> Business Type (Fill all that apply) 9 <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 /> 0 Service Station 0 Hauler Q Agriculture Q Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> "V A <br /> HAULING AND MANIFEST REQUIREMENTS p Q Notice Of Violation Q Extension <br /> Q 0 ,,PRC 42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 �RC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 1PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q in Compliance - No Violations <br /> 0 0 Other: § <br /> ' Comments <br /> Tk r I�-\v rr" �ciris CAV-9- nc 1, nQe C CC)n�-�Q;.Cd_ (A -t h 1 - _YI {__01i. <br /> .ACt_Ir czY C,C_cucc�,�l eco on -�_AC - !Fac <br /> 1 r� <br /> i <br /> Inspection Form Included 0' ' <br /> Comments Included �. ,. <br /> 0,Business Rep's Signature Phone Number Inspector's Signature y , Phone Number <br /> _ i <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 62081 <br /> % i E_ r� rpt M P 1 2 N 31 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />