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Waste Tire SAby & Inspection RepoA Inspection Report Number ■ <br /> State of California � <br /> s-6iii"1CIWMB181(New04/04) Survey Form - Page 1 ' <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN_ <br /> Ins l Business Profile Inspection Detai <br /> P <br /> TPID- _ Inspection Type (Fill one) <br /> T�T­ <br /> L4 <br /> Site Suffix: ` "T f ® Routine 0 Re-inspection 0 Referral 0 Observation !. <br /> Local — If Referral,choose referral type(Fill one) <br /> Identifier: C;r.ky) J o aq i4►rI pt���+�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address I 1 Q t <br /> Street <br /> Inspect n Date <br /> CA <br /> A � . 6 F-9_ 2- . ..__8 <br /> .1 <br /> State 'LIP Gode Time In Time Out <br /> 6_ <br /> Business Rep Title O AM — O AM <br /> 0 PM <br /> I <br /> Operational Status Tire Type I Business Role Strage Type <br /> The Count(Whole/PTE) (Fill one only) (Fill all that apply)II (Fill all that apply) (Fill all that apply), <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude Closed 0 Altered O Hauler 0Indoor <br /> �O Inactive 0 Truck <br /> Longitude — 0 Planned0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all tha pPIY) <br /> 0 New Tire Dealer 0 A ulo,Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other ,6 _ I; It c <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A !HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Respejhsible Entities Complying with Manifesting Requirements Date M / FF / T <br /> 0 0 14 CCR§ 18459.1 -Tire'Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 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 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § - - - <br /> Comments <br /> 1I t Q 'n� I.an o --L Ct1 — I Q I U ILA)c.-, In � <br /> Q E __0-Y a-c�,mto\jQjjC - o-r� c_ . T- -� fed ( y-� ever 'rrnr, r� , <br /> -A ���_r rnOT'e <br /> Tti'�rv_.. __�''1 f'..f,. _ ,• _ I - j t.=�f !1 4_: hn r ('-; L—f 1A3_L4 I✓- <br /> ,Inspection Form Included: 0 <br /> Comments Included: <br /> a ?sm2a -: ... ^ ; <br /> Business Reps Signature - Phone Number Inspectors Signature4 Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: incorrect: X G�,: � f R , 2T ! <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />