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® Waste Tire amu.. .y & Inspection Report nspection Report Number <br /> }idd3 State of California <br /> CIWMB 181(New 04/04) 1140855 Form - Page 1 I 1 - 114 0 8 5 5 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE_ OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> GSite Suffix: t (� Q 0 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��c„`, ,,-� (� -- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Busines/s�or Facility Name "�Y� Inspected By Inspector <br /> Physical Ad ss 3 ct l Q <br /> 11oInspection Date © <br /> [... G{� (� FIs��/Z 1 <br /> Time In Time Out <br /> Business Rep Title I ® AM ® AM <br /> Q PM + Q PM <br /> Operational Status <br /> Tire Type <br /> Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) f f <br /> ® Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) Nr A <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® 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 /> I <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 /> i <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> r- <br /> 0a <br /> Comments Included: fe - ���� y6 <br /> ��°�' '� — — - �ZGYs� $ <br /> Business Rep's Signatu�e Phone Number spector s Signature Phone Number <br /> . ._ -•- --•• - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: f” X A, L 1112131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop <br />