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Waste Tire S y & Inspection Repo <br /> ■ :: . � r%. Inspection Repor?; Number <br /> �m;7aCi State of California <br /> • CIWMB 181(New04/04) Survey Form - Page 1 11 - 1088376 <br /> California Integrated Waste Management Board Y `�J'' <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> 1 k - <br /> Business;Profile..g,� ;Inspection Details <br /> TPID- r-, ! / - Inspection Type (Fill one) --- — - - - <br />} Site Suffix: i , h f �f l O Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local f t If Referral,choose referral type(Fill one) <br /> Identifier: -it <br /> r, Y 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By <br /> Inspector <br /> Physical Address + r <br /> Street � p <br /> Ins ection Date I I <br /> ' City State ZIP Code Time In Time Out <br /> Business Rep Title �^ O AM f _ d Q AM <br /> PM PM <br /> i I Operational Status �, Business Role Storage Typ''e <br /> (Fill one only) (FtNir (i+�„ � (Fill all that apply) (Fill all that apply) <br /> 70,"ieliret ' <br /> �•+' 0 Active 0".P 5s t Generator 0 Outdoor <br /> Latitude O 0 Closed <br /> GPS � � • 0 Hauler 0 Indoor <br /> — O 0 Inactive ®:Truck <br /> Longitude - ! 1 7 E 0 <br /> 0 Planned 0°OTR End-Use 0 Container <br /> _ I <br /> Business Type (Fill all that apply) — - - - <br /> - - - <br /> 0 New Tire Dealer 0 Auto 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 (D Other <br /> -__j <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 /> I <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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments f[[{ E <br /> Ily )orf <br /> �Inspection Form Included 0 <br /> Comments Included: 01, , �__ • _-___ _ :. . _ <br /> 1 t3usmerss Reps Signature Phone Number Inspectgr s Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:i Incorrect: <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> I <br />