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- Waste Tire Suvy & Inspection Report 1nspection Report Number <br /> i83 Stateof California (a <br /> " CIWMB181(New04/04) Survey Form - Page 1 18 - 10 7 <br /> 1�— <br /> California Integrated Waste Management Board ------ <br /> Part A- Survev BLUE OR BLACK INK PEN <br /> TPID- f� �.j (, Inspection Type (Fill one) <br /> Site Suffix: J / rJ (a Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. JI ,; f/I ( , Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> L LC___ <br /> - --- <br /> Physical Address <br /> LULU L <br /> Street <br /> Inspection Date <br /> I �' � � � � /r .i I Time In ' Time Out <br /> City T State ZIP Code _- _ ___-- <br /> Business Rep Title O AM O AM <br /> ✓.'yl :1 r.. O PM 0 PM <br /> Operational Status 1 ire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ire Count(Whole/PT <br /> _ Q Active Q Passenger Q Generator Q Outdoor <br /> ^ O Q Closed Q Altered <br /> Latitude <br /> GPS m <br /> Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <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 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 /> 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 /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <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 Q, 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> (D 0 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 /> Q Q Other: § <br /> Comments _- <br /> .1 f <br /> and (v^.t ! _T__flEYtla �•l 11► f� f !!I L�Cr ck' L �� �. L- <br /> 1 <br /> V1i�t'.1F'� �)t( -�-'/C!';C /rt e/F Jrt ��i f� %L:( <Gf -- ( /,jL <br /> lit In <br /> Inspection Form Included: <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Numbe <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �r" , \/ I L X i M P L i U1 I'2 1 3 I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />