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Waste Tire Surf@y & inspection Report Shispection Report Number <br /> ® State of California <br /> WA <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I � - 1127634 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br />} TPID- Inspection Type (Fill one) <br /> Site Suffix: Routine Re-inspection Referral Observation <br /> 0 P <br /> Local _ _ i If Referral,choose referral type(Fill one) <br /> Identifier: ' :E ,t y,t' (. 9 Q CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 7 2 - C; ) <br /> Physical Address �J ��� i E'!''1✓l. 6�0 <br /> ....JQ4I <br /> St;ei <br /> Inspection Date <br /> _f I <br /> 3 <br /> :p C, Time In Time Out <br /> ... <br /> Business Rep Title s <br /> O AM O� i / AM <br /> OPM0 PM7 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) IFill all that apply) (Fill all that apply) (Fill all thiat-,reply) <br /> 9 ? <br /> e 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O O Closed Altered <br /> GPS Latitude �H^ i 0 Hauler 0 Indoor <br /> O Inactive 0 truck <br /> o <br /> Longitude _ ( PlOTI, End-Use 0 Container <br /> Q Planned 0 <br /> n <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O 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 <br /> ------- _--- — -- -- 0 Notice Of Violation D Extension <br /> Q 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 /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 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 0 in Compliance - No Violations <br /> 0 0 Other: § /-` <br /> Comments .e I. 1° J ( tJZ <br /> b5 ScGt o-Wr f-vf -fire 5ervE c� x,' Po s,�, NO* <br /> No I'?T(- fVl 0 n F,11 f- f"' <, �t}'y vrt Z-e S/ _SCA W0 6/ as, rl o _. <br /> ri 4-r- - .1 wF /-•- .-• -� f!!.1 j,l t '?I/1!1.T� ?°I/' l r, -a T r';- ` <br /> Inspection Form Included: 0 <br /> I <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspectors S)gnature Phone Nurnber <br /> _ 6208I <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: �/ tom, , 1 �;� <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />