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■ Waste Tire S ey-& Inspection Repornspection Report Number ■ <br /> �.:I State of California i �"`- -7 � � t=; ACIWM8181(New 04/04) Survey Form - Page 1 s f I <br /> California Integrated Waste Management Board - - <br /> Part A- Survey BLUE 0 R.-B. -LACK INK PEN <br /> Business Profile,- I Inspectoh Details <br /> TPID- a �j �7 /f'�� Inspection Type (Fill one) <br /> Site Suffix: I /�/ �l / / V� it Routine Q Re-inspection Q Referral Q Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: �/t N J t `f�� r rw �O(��J i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �LI Nit _ / / <br /> Physical A dress -----T f ,� /% <br /> Ll <br /> Street Inspection Date <br /> City State ZIP Code Time In Time Out _ <br /> Business Rep 'Title - - 0 AM -y — 0 AM <br /> _ PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Closed Q Altered g Q Q Outdoor <br /> MNNN1E=1=�( Active Passenger Generator <br /> Latitude E <br /> - p Q QGPS 1.-__ [ Q Hauler Q Indoor <br /> - Q Inactive Q Truck <br /> O <br /> __._��_.._�_.._ �_ -_ - Q End-Use Q Container <br /> Longitude - Q Planned Q OTR <br /> Business 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 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> §- g - - -- -- -- - Q Notice Of Violation Q Extension <br /> V I A ',HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC 42951 -Waste Tire Hauler Re istration 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 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers i 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: § -- -- -- - -1i <br /> Comments • rr <br /> > '1 � <br /> J <br /> C . p /F �> tt bi>~it °1 �11 <br /> Inspection Form Included: Q <br /> Comments Included: s ,w -- <br /> Business Rep's Signature Phone Number Inspector's Signature , ,t Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 62081 <br /> L _ P G E 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />