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Waste Tire SuAft & Inspection Report ispection Report Number ■ <br /> &C@35 State of California r -^ <br /> CIWMB 181(New 04104) Survey Form - Page 1 l 4► ; 1 �t _Y <br /> California Integrated Waste Management Board g <br /> Part A- Survey __ BLUE OR BLACK INK PEN <br /> BusfnssJXF <br /> - <br /> �• TPID- 7 _ Inspection Type (Fill one) <br /> �-,Site Suffix: S (0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other . <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> Ph s'ical Address - - <br /> � _ f <br /> Strom et <br /> 1., w Inspection Date <br /> City Stale ZIp Code Time In Time Out <br /> Business Rep Title LTJ [___ <br /> Q AM Q AM <br /> 0 PM - - PM <br /> F-1 <br /> 777 <br /> Operational Status Type Business Role Storage Ty <br /> The COUnt(WhOle1PTE� (Fill one only) (Fill all that apFill all that apply) (FIII all that ap(31y <br /> Active Q Pas'songer, Q Generator 00 t <br /> Latitude 1 D Q Closed Q;Altred ' <br /> GPS L ti Q Hauler Q Indoor <br /> Q Inactive Q 1 Truck a <br /> Longitude �O Planned Q pT�{ n <br /> Q d-Use Q C <br /> Q Eontainer <br /> Business Type (Fill all pplll � ,•pA „,. % _ 1 <br /> Q New Tire Dealer Q Auto Repair 0-Tr ucking 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 FIAAULING AND MANIFEST REQUIREMENTS <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 m m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 014 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforcement <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 /> ' Q In Compliance - No Violations <br /> Q Q Other: § <br /> - --- — <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included Q - — -- - --- - _ _ --- - <br /> Business Rep's Signature- Phone Number Inspector's Signature Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />