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032100.40255 <br /> HM <br /> Waste Tire Surty & Inspection Report Inspection Report Number <br /> State�.� CIWM ornia . Survey Form - Page 1 1 6 - 1 0 1 9 3 3 6 <br /> CIWMB 181 181((New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- f^ Inspection Type (Fill one) <br /> Site Suffix: a 3 J a ► O I le Routine Q Re-inspection Q Referral Q Observation <br /> Locales If Referral,choose referral type(Fill one) <br /> Identifier: Sko �+.� urn Lbu, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addres� <br /> Street a <br /> Inspection Date <br /> �e�. _ r/a <br /> City 0� State ZIP Code Time In Time Out <br /> Business Rep Title 0AM 0 AM <br /> ` ao�r EJ4D PM I ®I ] PM <br /> Operational Status Tire.Type Business Role Storage Type <br /> 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Active O Passenger ® Generator 0 Outdoor <br /> 1 D Q Closed Altered GPS Latitude �I f j I� ! � Q Hauler Q Indoor <br /> I0 Q Inactive ®Truck <br /> Longitude FTP <br /> . �� 1 I 1 Q Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 111 111 <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader • Dismantler 0 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 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 <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 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 In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments ��, 1c� - �- -- -.diva--4n---`S� - e.�� -� ��n9-w<s�-1 --u�►�,- <br /> n� <br /> La <br /> I J <br /> Inspection Form Included: Q (� Q R <br /> Comments Included: Q — - — `=i <br /> usin ep's Signature Phone Number Inspe or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C rrect. Incorrect: ( X .Ahh PL111273 <br /> White Cop CIWM Yellow Copy Operator Pink Copy-LEA <br />