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F, Waste Tire Si. _-ey & Inspection Repot Inspection Report Number ■ <br /> CIWMBB 181(New 04/04) <br /> State California S u rveY Form - Page 1 Il - 1127664 <br /> California Integrated Waste Management Board <br /> PartA- Survey_ - -__ — BLUE OR BLACK INK PEN <br /> Business Profile .Inspection Details <br /> TPID- � � � O � � -7 _ � 1 Inspection Type (Fill one) <br /> Site Suffix: I' Routine ® Re-inspection Q Referral Q Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: � <br /> �5a V1 <br /> � , If Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address Z <br /> l'rCn'1 Y? rill 111►►►CUUL„rn ry„ <br /> cA Inspection Date l f <br /> "` Time In Time Out <br /> Business Rep Title J ® AM 0 AM <br /> l o O PM G z lJ ®PM <br /> lt-i-b Py r�, e �c�Yl '.✓ -- - -- <br /> -------- - — -- - — -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 9 Active 0 Passenger 0 Generator • Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - O Planned Q OTR O End-Use Q 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 O Tire Derived Fuel <br /> ® Used Tire Dealer O Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> I V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 O ; 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators • In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> !Inspection Form Included: Q <br /> Comments Included: ---- - - ----- - --- ----.- <br /> Business Rep's Signature umber In ect is na re Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: _j I E X A P 112 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C per <br /> ® ■ <br />