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Waste Tire Suwy & Inspection Reports Inspection Report Number <br /> State of California () ; <br /> CIWM6181(New04/04) Survey Form - Page 1 _ � ' <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> [ ] <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: I / �� 10�3 Z � 6]-1 Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 9} ,. 1 _J r„ ., 1.�!/\/ U t1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name n Inspected By Inspector <br /> Physical Address <br /> 67 2�? W,° S Te G i <br /> Street D ✓ F2F?� <br /> State Z PCode <br /> / m <br /> » �,t Inspection Date <br /> r' ��Z /Code I Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> CYT QPM � ' EF <br /> 0P <br /> t r�n�f <br /> I I I Operational Status Tire Type --Business Role —' Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPs Latitude i I I . Q Hauler Q Indoor <br /> D 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 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 / m <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 /> 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 <br /> Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments --7 <br /> 3 All <br /> A T ��2 ��nllc'tb► �JrS 7� <br /> Inspection Form Included: Q <br /> Comments Included: Q Business Rep's Signature Phone <br /> Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: X j E 0 A !� P L ��ET I <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />