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Waste Tire SuW & Inspection Repor tionReport Number ■ <br /> State of California <br /> BS89 CIWM6181(New04/04) Survey Form - Page-1 • 5 <br /> California Integrated Waste-Management Board - ------ _ --- -_.-- <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix. J� J 7 .. ?' ( #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 /> Business or Facility Name Inspected By Inspector <br /> I <br /> Physical Address <br /> j - - <br /> j <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title % i 7 0 AM O AM <br /> O PM l O PM <br /> Type <br /> Operational Status Tire T e Business Role Storage Type <br /> - P <br /> Fill one only) (Fill all that apply): (Fill all that apply) (Fill all that apply)', <br /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered r <br /> ::Longitude!_ <br /> 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> 0 Planned 0 OTR 0 End Use 0 Container <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 ® 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 Notice Of Violation 0 Extension <br /> 0 0 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 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 I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> 0 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 � \ ? ie <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />