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Waste Tire S __ i - <br /> y & Inspection Repo Inspection Report Number <br /> a� StyatMB181i(New g SurveyForm Page 1 <br /> _- <br /> CIWMB 781 New 04/04 <br /> California Integrated Waste Management Board g j 1 0 6 6 3 2 <br /> Part A Surve - <br /> ,�y BLUE OR BLACK INK PEN <br /> BUSITIEp <br /> ection T <br /> = <br /> TPID- Ins � <br /> Site Suffix: � - � p Ype (Fill one) <br /> @ <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: CHP <br /> -` Q Q CIWMB Q Complaint Educational Visit Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 4-\ _. <br /> Physical Address - <br /> L — T�� _ <br /> i 4 - <br /> Street I - <br /> ,� Inspection Date <br /> Crty State ZlP Code Time In Time Out <br /> Business Rep Title AM <br /> AM <br /> O PM0 PM <br /> _ <br /> m _ . Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (r=ill all that apply)' (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude m . 70 Q Closed O_Altered <br /> Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - � <br /> 7TI. FT-F77-� Q Planned Q OTR Q End-Use Q Container <br /> Esusi l ss`Fye (;-ill all th t apply) - <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q The 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 /> --.- -- <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 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 1 Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire 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 /> i §, <br /> Q In Compliance - No Violations <br /> Q Q Other: <br /> Comments <br /> A_ <br /> b.ti <br /> —----------- --- <br /> Inspection Form Included: Q, <br /> Comments Included: Q' - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK Correct:® Incorrect: X Ito, L I � 62081 <br /> s° - - . ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br />