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Waste Tire Stey & Inspection Repo Fr <br /> - <br /> Inspection Report Number � <br /> / - -,w State of California I - 1 0 6 6 9 7 4 <br /> CIWMB 181(New 04/04) <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A Survey - - <br /> Busim P ggxsl AA <br /> F Inspection Details „ m <br />} TPID- t _ Hij <br /> Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection Q Referral Q Observation <br /> 1TTLocal t If Referral,choose referral type(Fill one) <br /> Identifier: f ; 1 i r ' 1 t!� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> -----.,_ - <br /> -;E, <br /> Physical Address <br /> - , <br /> Street <br /> LU <br /> Inspection Date / <br /> ICA <br /> ------ _. ...— . _._._ TI <br /> .._. Mate ZIP Code- ._._ime__n Time Out <br /> ...._ � <br /> �. <br /> Business Rep Title ( II �� -� AM f `` PM <br /> i <br /> ... O PM ._9 <br /> r•....i ! 4�V' I !f'�_J ! i�{':.(' j-E''tr - --�-^--F;4 ,,rr ''- . <br /> l — Operational Status tre Ty Business Role ftofage Type <br /> jj <br /> (Fill one only) rI (Fill all that apply) (FIN all that apply) <br /> v= Q Active Q Generator x,Q Outdoor' <br /> _ <br /> % <br /> Q Closed <br /> ��� Latitude Q Hauler �Q Indoor <br /> Q Inactive <br /> Longitude - i Q Planned Q End-Use vQ Container <br /> ,Bu s Type :(Fill all'that a <br /> QNew11 <br /> Tire Dealer Q Auto Repair S 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS - -' <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 <br /> ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> I <br /> (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 Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance No Violations <br /> O Q Other: § — — -. <br /> Comments <br /> i <br /> Inspection Form Included:.Q� <br /> ` <br /> Ins ! <br /> �.. <br /> C+ Sig <br /> i Business Rep's nature hone Numb Inspector's Signature Phone NumUer' <br /> Number P <br /> - <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA - <br />