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Waste Tire Su y & Inspection Report Inspection Report Number ■ <br /> State B California Survey Form - Page 1 [-J_ 3 �+ 4 <br /> G5i3a CIWMB 181(New 04/04) ag <br /> California Integrated Waste Management Board -- --- -��------ - - --- - ----- - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> f <br /> I TPID- ii Inspection Type (Fill one) <br /> Site Suffix: Z � t � f! D.Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ' If Referral,choose referral type(Fill one) <br /> Identifier: <br /> (.( 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Ph sicaI Address <br /> y <br /> -�_. f •.� _� _ _ <br /> Street Inspection Date j 1 <br /> I_-- __— _ <br /> (i!y �tate�P Code I Time In Time Out E[J- : _._ <br /> Business Rep Title �1 O AM AM <br /> 1 <br /> EL �I IPM OPM <br /> t--`. <br /> �f Operational Status Tire'' r ati,`�,' F Business Role Storage Type <br /> (Fill one only) (Fill all pply� (Fill all that apply) (Fill all that apply)'; <br /> �1� m < � r ® Active <br /> CRI, (� Past t ai ET_ Q Generator 0 Outdoor <br /> LL99=1 GPSLatitude 0 ClosedO Hauler���III 1 <br /> 0 indoor <br /> LLL0 Inactive 0 Truck �� t' <br /> Longitude — 7171----_ ���� <br /> 0 Planned 0 OTR 0 End-Use 0 Container <br /> usi e s Type (€iil all t,;^at apply) -. <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m T / m <br /> 0 @ 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 901days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred i CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § --- <br /> Comments !� } <br /> Inspection Form Included: 0 <br /> Comments Included: 0 _ -- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X I �' _A <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />