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j Waste Tire Su & Inspection Report nspection Report Number <br /> - St ateCalifornia Survey Form - Page 0 7 9 14 0 <br /> iii7 CIWMBB181(New 04/04) I � - <br /> California Integrated Waste Management Board : <br /> Part A- Survey BLUE OR BLACK INK PEN <br />} TPID- _ - inspection Type (Fill one) <br /> Site Suffix: � Q Routine Q Re-inspection Q Referral Q Observation <br /> Local )Y / If Referral,choose referral type(Fill one) <br /> Identifier: r ;: i t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t Inspected By Inspector <br /> 1 <br /> r, ca <br /> Physical Address <br /> Street T- <br /> f.' Inspecton Date <br /> �- <br /> f Z�' ✓yl/` (�i ! C!i'Vl b"�, t- '�''°'�--� 'I r <br /> City T State ZIP Code Time In Time Out <br /> Business Rep Title rn <br /> FT <br /> 0 AM 0 AM <br /> _} t - �0PM � m 0 P <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) <br /> Active Q Passenger Q Generator Q Outdoor <br /> - m O <br /> GPS Latitude I Q Closed Q Altered <br /> O Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - i Q Planned O 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 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 (6) Other ,'1 t (` <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING 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 O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforcement <br /> Q O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities - <br /> Q O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> O Q Other: § - - <br /> Comments <br /> r ha/h (11 Y� . I �,rf f fi? ' i o ec( / ,tr h161G1�(+� <br /> AY <br /> Inspection Form Included: Q <br /> Comments Included: 0 -- - <br /> ---- - -- <br /> Business Rep s Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: X �E X R N, '�� L. Z C 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />