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® Waste Tire Sun*& Inspection Reportob0pection Report Number <br /> State of California <br /> 'r CIWMB 181 teManage) Survey Form - Page 1 1141185 <br /> California Integrated Waste Management Board _ __ __ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ( I �J 1 l Inspection Type (Fill one) <br /> Site Suffix: ` S I "l I i 1 1 i <br /> I �mm L_„�� _ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - - - <br /> Inspected By Inspector <br /> i �t�AL mc:� J ; _ i /� <br /> Physical Address { j ) I ! T <br /> 7 un <br /> St,eel <br /> 1 / Inspection Date I <br /> r NSe <br /> ZIP Code Time In Time Out <br /> Business Rep Title �.... ...... ........... O AM 0 AM <br /> l I0P OPM <br /> Operational Status Tire Type Business Role Storage Type <br /> I irk tint(1NholelPTE� i (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passehget 0 Generator 0 Outdoor <br /> O 0 Closed 0 Aneroid <br /> GEIS Latitude � ; I I 0 Hauler (� indoor <br /> �._... -. _._a ..__., L.. __ <br /> _...__ __... r . .._. �. 0 0 Inactive C Truck <br /> Longitude - i 0 Planned 0 OTR 0 End-Use 0 Container <br /> usiness Type (Fill aft th ,t apply} <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet D 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 / E] <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 /> 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 <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Commentst <br /> `� Oct -i <br /> Inspection Form Included: 0 -- <br /> Comments included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X o�, :X� -A "A�-P _ <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />