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Waste Tire Surly & Inspection Report Ahnspection Report Number <br /> ka <br /> State of California CIWM6181(New04/04) Survey Form - Paige 1 4 - 10 1 r 2 9 <br /> California Integrated Waste Management Board J J - - <br /> Part A Surve BLUE OR BLACK INK PEN <br /> TPIsite - Inspection Type (Fill one) <br /> Site Suffix: `�✓ � '� � � Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �. v- r 1,. N_ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street t <br /> Inspection Date <br /> " <br /> City State ZIP Code Time In t� Time Out <br /> Business Rep Title AM AM <br /> 0 PM FH : D. O PM <br /> t7lOp erational Status Ti e Type <br /> Business Role F Storage Type <br /> (Fill one only) (Fill SII that apply)' (Fill all that apply) (Fill all that apply). <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> EEI <br /> Closed Q AlteredGPS Latitude , �O . Q Hauler Q L�dcor <br /> � Q Inactive Q Truck <br /> Longitude - � I Q Planned Q OTRQ End-Use Q Container <br /> f <br /> Business Type (Fill all tat 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 STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O Q PR - ---- Q Notice Of Violation Q Extension <br /> C§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 mm / m <br /> ii <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 <br /> 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 /> 14 CCR§18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q - anem Q In Compliance - No Violations <br /> Q OOther: § <br /> i <br /> Comments <br /> Inspection Form Included: <br /> Comments included: Q <br /> Business Rep's Signature Phone Number Inspector s Signature _Phone Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X V iy: X I A Ml P I L l - T <br /> ■ White Copy:CIWMB Yellow Copy:Operator a Pink Copy:LEA ® ■ <br /> I <br />