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Waste Tire SA.ey & Inspection Reporo. Inspection ReportNumber ■ <br /> ■ 6 uG9. State of California - e-F{Page 1 7 � %1j <br /> ®� CIWMB 181(New 04/04) Survey Form IJ 3 .... <br /> California Integrated Waste Management Board ! - <br /> Part A Survey _ BLUE OR BLACK INK PEN <br /> � tIvS�SS Profile SFr 'Inspection Dekaitls s 11 <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ( ) � ® Routine Q Re inspection Q Referral Q Observation <br /> Local <br /> Identifier: ` d u If Referral,choose referral type(Fill one) <br /> , _ <br /> i ; ,r t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address --- --�- (� - `i I n - r <br /> 51 i <br /> Street —y L_._` a] / <br /> Inspection Date L(J r <br /> .__ .1 Time In Time Out <br /> Yate ZIP Cil e <br /> Business Rep Title O AM AM <br /> E_ 0PM � -._ OPM <br /> � ----� -'"�_� —""—�'��'' — Operational Status Tire Type Business Role Storage Type <br /> N (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)', <br /> I <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> �p D Q Closed Q Altered <br /> GPS Latitude ELI <br /> , I_ ��- Q Hauler Q Indoor <br /> - J ii.. III Q Inactive Q Truck <br /> Long L_. 90 Q- Q Q End Use Q Container <br /> Lon Rude Planned OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder I& Other "rc�'K <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / FF] <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 1 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q 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 I Q In Compliance - No Violations <br /> Q O Other: § -- <br /> Comments l <br /> !�C6, r ? ,'T. 1' j'''`. - <br /> J <br /> i <br /> rt C7 �� t ,J► _p-Q__ +,t,_� , 7 yrsCo . If C2"4-'_-a-—La 1s= <br /> C <br /> iTq �( <br /> rt G <br /> T <br /> Inspection Form Included: Q'j <br /> Comments Included: <br /> In a for Snat ; LL <br /> Q',Business Reps Signature Phone Number t ure-- , _ F ,. l__9, _ . . Phone Number_. ----- - _— <br /> 0 62081 <br /> Incorrect: <br /> ■ INSTRUCTIONS ON BACK Correct: <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />