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Waste Tire Sd%ey & Inspection Reporo Inspection Reporty�Number ■ <br /> •n-Hws" state of California 1 1 ® � L 1 <br /> CIWMB 181(New 04/04) Survey Form - Page <br /> �i -... --.._ - <br /> California Integrated Waste Management Board <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profi,,,l . z Ins ecticn D ai <br /> p et Is <br /> O . _ L�L <br /> _ <br /> L I - <br /> TPID- � Inspection Type (Fill one) <br />} i <br /> Site Suffix: 1§ Routine Q Re-inspection Q Referral Q Observation <br /> - San 7C)(a �n Cauhi- --- <br /> � Local If Referral,choose referral type(Fill one) <br /> Identifier: 9� ty Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> J - <br /> l.. y ''(eco L�T� LK � <br /> Physical Address Y 1`��,G Yl I_U C G`, i <br /> L_ �.��75 5�1r��O1(l <br /> �. ----- <br /> Street Inspection Date Lo—i8J <br /> �G;zobiTime.-Out <br /> l— -- ------ Time In Time Out <br /> ____- ._-.-- St<ate ZfP Code Q AM r . F_�7 <br /> QPM <br /> �a.] : <br /> PM Business Rep Title (roods ....._.-._— OAMQ <br /> —.. t - .._.. -.- - -_ - <br /> �u -G w e r 2 f l QI L_L_ Cl- <a{o r _� , <br /> Operational Status Tire Type Business Role Storage Type <br /> P (Fill one only) (Fill all that apply)', (Fill all that apply) (Fill all that apply) <br /> 4 ® Active 0 Passenger Generator Q Outdoor <br /> Q Closed 0 Altered <br /> Latitude <br /> Q Hauler Q IndoorGPS LJ 0 Inactive J Truck <br /> l0 <br /> Longitude r� <br /> �� Q Planned 0 OTR <br /> Q End-Use 0 Container <br /> -_ _ -°- - - <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler O Agriculture Q Shredder Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility l_ENFORCE MEN T STATUS <br /> V1 A 'HAULING-AND MANIFEST REQUIREMENTS O Notice Of Violation 0 Extension <br /> O O I PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> O Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O 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 /> m Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18461 -Manifest Syste <br /> -- -- -- <br /> 0 O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Cimpliance - No Violations <br /> Q Other: § <br /> romments da-ve 4-'e o IIo� lh wCIS <br /> acY d+-,C+ fy)6n .�t'��rcd b J06 <br /> o T_ _e1, 5 Se r,j I C Q CA o �- ► c <br /> re �q C 1f1QS �' n _ _ 4-c <br /> fir- - - 4 T e C' <br /> Inspection Form Included: 0'! <br /> Comments Included: 0,Business Rep's` Signature Phone Number dl slleclor's Signature f- Phone i4a ar i)er <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X AAM PL <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />