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® Waste Tire Siey & Inspection Repor1l'' -- Inspption Report Number <br /> ••° State of California <br /> Survey Form - Page 1 i i - 10067 4 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board ___ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPItt I <br /> Sux: �pection Type (Fill one) <br />} Site - <br /> Site ffi ( Ins <br /> ' Routine 0 Re-inspection 0 Referral 0Observation I, <br /> Local If Referral,choose referral type(Fill one) <br /> Identifie •or Facility Nam �G Cl'V-1 t-N 0((Kf CA, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business y e <br /> _ --- 7C.1`I <br /> Inspected By Inspector <br /> oc <br /> Physical Address _ j Cr <br /> Street <br /> Inspection Date <br /> City State Zip Code Time In Time Out <br /> - -- <br /> Business Rep Title ( O AM 'f\ / O AM <br /> - 0 PM 1. I l� Q 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 /> The Count(wnolefPTE) CJ <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude m 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> 1,0 <br /> F'be 0 New Tire Dealer 0 Auto Repair ® 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 0 Other <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 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 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire 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 0 In Compliance - No Violations <br /> 0 1 0 Other: § -- J <br /> Comments <br /> II f�-.�r-� - <br /> �tet_S �7�tCk�v1`t J-PP OF � ��'C u� 1 t� �' �tce�4F> lSf I t/[' �L �t/Ie Gi .:; <br /> 1 <br /> v <br /> 1 1''tj11�Ck �'tt � i f bmiltriD' i1 ( tJC. 1� 6l .FC1 G`:;} i "CUr <br /> / n. �{�J •,-�.I -(" 4 ; 1 —r- )( gyp! r <br /> Inspection Form Included: 0 <br /> Comments Included: 0 _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> ■ <br /> I� <br />