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Waste Tire Su- . Jy & Inspection Report _Inspection Report Number <br /> State CIWM f 81(New <br /> Survey Form - Page 1 i 9 - 1 0 0 0 2 2 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> C'\ <br /> Site Suffix: 1 Z - \ - 0 ` iV Routine Q Re-inspection Q Referral - Q Observation <br /> Local _ l If Referral,choose referral type(Fill one) <br /> Identifier: SCt,V-" a�q,.t�-tom n�l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business for Facility Name U l Inspected By Inspector <br /> Physical Address3 - <br /> Inspection Date v <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> CD 7 t7 0 PM PM <br /> - - - - <br /> Operationalerational Status Tire Type <br /> Business (ll <br /> (Fill all that apply)' <br /> (Fill all that apply) all that apply) <br /> Tire Count (Whole/PTE) (Fill one only) <br /> f f Q Active Q Passenger Q Generator Q Outdoor <br /> a O ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O i Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <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 I ENFORCEMENT STATUS <br /> V A 1 HAULING AND MANIFEST REQUIREMENTS ^T <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§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 <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB l ' <br /> (Required for NOV or F_XT) <br /> Q Q <br /> 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 daysrt r.. <br /> Q 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 eerr CIWMB E orCerne r; <br /> i icy u �, ��•��"'� �r" '�s"�S{., � ;c <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 /> (�In Comp'arice No Vwia47ons <br /> QL Q 'Other: § ---- - — <br /> Comments _lZ _l\�C� <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Ins ector's Sign ure Phone Number <br /> INSTRUCTIONS ON BACK (Correct Incorrect I �,X AA p E Z 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />