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Waste Tire SuWy & Inspection Report ispection Report Number <br /> �a� State California Survey Form - Page 1 3 - 0 7 3 <br /> CIWMBB 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 /> Inspection Type (Fill one) <br /> Site Suffix: } (( <br /> TPID- J ,' I�J Routine Q Re-inspection Q Referral Q Observation <br /> Localr1 I If Referral,choose referral type(Fill one) <br /> Identifier: �; <br /> •',((t,'�. )((Q�1 �`• � �(.(���_ -- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility ame 01;.1 <br /> , Inspected By Inspector <br /> Physical Address l Q fro S <br /> Street <br /> _ C L Inspection DateFOE ✓ m <br /> City State ZIP Code Time In _ Time Out <br /> Business Rep TitleO AM m m Q AM <br /> -� � �� 0 P �I �1 1 0 P <br /> Operational Status Tire Type 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 <br /> (a Active Q Passenger Q Generator Q Outdoor 1 171 <br /> � Q Closed Q Altered <br /> GPS Latitude mF7 F Q Hauler Moor <br /> Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container 10 <br /> I : <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 i <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 /> 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 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 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 1 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 )rti.. r }�l a ` r j IWO � Y1 i?��;� . <br /> car . ; J Fled <br /> �J� t r r '5��1 � r'•f (1t, I T'fl t� _ i I�� i ( Ph f'f/lC�til <br /> �l_`; ff t � �1 c, - <br /> Inspection Form Included: <br /> Comments Included: Q <br /> �u Business Rep's Signature Phone Number Inspector's ftnatur Phone Number <br /> INSTRUCTIONS ON BACK Correct:18 Incorrect: X d _,A_1,�1PjL1E1 1112131 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />