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Waste Tire Survey & Inspection Repol"lnspection Report Number <br /> � Iii¢:• p � <br /> State of California I 1 - 1127879 <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> _ _ BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Inspection Details <br /> Business Profile _ <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 4-1 3 <br /> t 3 � � L �Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��i1 -IX �� CeVVU. U --- -OCHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> V <br /> Business or Facility Name ( Inspected By Inspector <br /> i vL5�,✓ L__uyAbe,; 59 <br /> _ 1_01 <br /> ]) fwL /�w J6 <br /> Physical Address ht. _o /]r►' , y <br /> G�_ <br /> �.1 Inspection Date i 1 1 <br /> �- J 5d� I Time In I Timle Out t <br /> Business Rep Title AM yy O AM <br /> 3 O PM 1 Z ® 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) f <br /> ® Active Q Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> - 0 Q Inactive ®Truck I <br /> Longitude - Q Planned OTR Q End-Use I 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 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 ® Other L�,tvr1 � GC✓�J <br /> ----- -- --- - <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q i 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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!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 &In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments / <br /> G � <br /> Inspection Form Included: QI! <br /> Comments Included: ®� - ©` -`c J `l <br /> Business hp's Signature Phone Number Insp ct 's i ure Phone Number <br /> - ---- _ - - - - .. - - - - <br /> - --- _ - -- 62081 <br /> INSTRUCTIONS ON BACK ' Correct:* Incorrect: X X R M S 3 <br /> -_ -- © ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co :L <br />