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section Report Number <br /> p pp p <br /> Waste Tire Su & Ins Inspection Report <br /> California <br /> B 81(New t <br /> CIWM6181(New04/04) Survey Form - Page 1 ° r� J) <br /> Integrated Waste Management Board - - - "-' <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business Profile <br /> r . <br /> TPID- 1� r Inspection Type (Fill one) <br /> Site Suffix: / `. 1 Routine Q Re inspection Q Referral Q Observation <br /> ----- - ----— <br /> Local �- t If Referral,choose referral type(Fill one) <br /> Identifier: r ,r !„(a r r Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name /rl Inspected By Inspector <br /> Physical Address E ( - 11 <br /> 1LI - <br /> t .-- I • . !, (:• � ,: � Inspection Date l r I <br /> -- Time In Time Out <br /> State ZIF Code . F _._._ <br /> Business Rep Title O AM O AM <br /> _T <br /> OPM ���� � _. OPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Fill all that apply) <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) ( pp y)' <br /> Tire Count (Whole/PTE) <br /> 7 r Q Active Q Passenger Q Generator Q Outdoor <br /> _ Latitude 0D Closed � O <br /> Altered <br /> GPS ���� O Hauler <br /> Indoor E _ Q Inactive Q Truck <br /> Q End-Use Q Container <br /> Longitude F1 Planned O OTR1-7777-T O <br /> _ - <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 j <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 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 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 /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q O14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> O (Required for NOV or EXT) <br /> O 14 CCR§ 18459.2.1 -SubmittlfComTrip Logs 90 days <br /> Q Q 14 CCR§18459.3 Comprehensive Trip <br /> years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 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 Q In Compliance - No Violations <br /> O O Other: § _.. <br /> Comments <br /> Inspection Form Included: Q' <br /> Comments Included: Q - _ _- <br /> Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> p 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X _x:i A h0il PTL I , 23 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />