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EE <br /> Waste Tire S & Inspection Reporift <br /> Report Number <br /> State of California _ -- - <br /> E Survey Form Page 1 <br /> CIWMB 181(New 04/04) i ; 7 ` LAI <br /> 0 <br /> California Integrated Waste Management Board r a �+ -. r <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> "' <br /> .a a••,.� ,�^.�,� �w,4 c�� .�w .?�,i �.'m�"��' ��, '�X'i 5� h � �"u ^ ""^�i4,,z , <br /> TPID- (- ' Inspection Type (Fill one) <br /> Site Suffix: T ? Routine Re-inspection® Q P Q Referral Q Observation <br /> -- Local - - _ _ -- <br /> t If Referral,choose referral type(Fill one) <br /> Identifier:('( - <br /> tr (.• q <br /> 6 � ' { c• i', Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name B <br /> Inspected - <br /> Ins <br /> -- p Y Inspector <br /> Physical Address E { r <br /> Street <br /> Inspection Date <br /> City ^� State Z/P�- Gode Time In Time Out 0 AM <br /> Business RepQ AM <br /> Title <br /> ®r. <br /> Operational Status i Tire T e Business Role Stora e TYp g ype <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)\ 1� Active I Q Passenger Q Generator Q Outdoor <br /> i O Q Closed Q AlteredS Latitude — �� 1 Q Hauler Q Indoor <br /> _f Q Inactive Q Truck <br /> Q Planned Q OTR Q End-Use Q <br /> Longitude - 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 STAT <br /> A HAULING AND MANIFEST REQUIREMENTS US <br /> V - - ---- -- �� <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 -Tire Program ID Number from CIWMB m m m <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 Q Other: § Q In Compliance - No Violations Comments - <br /> "`� tw ( i.. td <br /> . f <br /> �ij If <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: µ; tl �? rF 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br /> i <br />