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a <br /> Waste Tire Su Ins ection Re ort Number <br /> State of California y & Inspection Report __p ._p __� n <br /> CIWMB181(New04/04) Survey Form - Page 1 L 7 - 10 0 6 6 � <br /> California Integrated Waste Management Board BLUE BLUE BLACK K INK PEN <br /> BLAC <br /> Part A- Surve <br /> Inspection Details <br /> TPID- s Inspection Type (Fill one) <br /> Site Suffix: 5T, ? jc j � j 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> --- L <br /> Business or Facility Name t Inspected By Inspector <br /> Physical Address 5 _1 <br /> Street Inspection Date <br /> i Time In Time Out <br /> City State ZIP Code -_ _F —7 <br /> Business Rep Title ` 0 AM M <br /> 0 PM 0 PM <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 /> Active 0 Passenger 0 Generator 0 Outdoor <br /> �..- ---��D 0 Closed Altered <br /> GPS Latitude 0 , <br /> � 0 Inactive 0 Truck 0 Hauler Olndoar <br /> Longitude 1 1 17 <br /> 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> w <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 0 - 0 Notice Of Violation 0 Extension <br /> 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 <br /> M / m / m <br /> 0 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 90 days (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/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> 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 V <br /> ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />