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f <br /> Ai Waste Tire S48W Inspection Repo4owection Report Number <br /> z1 W State of California 1 <br /> CIWMB 181(New 04/04) Survey Form — Page I + — 1141250 <br /> California Integrated Waste Management Board J g - - - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> 134 ess Profile Inspection Details <br /> TPID- '� ` t - �. € _ Inspection Type (Fill one) <br /> Site Suffix: <br /> �_ � � � �i,, Q Routine O Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: t \'C C� um Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> _ j f <br /> Physical Address <br /> ............... _._-.:5 .._.....-._..........- .. ........._._......_. ..........._......_....._J l <br /> S -et -7 <br /> Inspection Date <br /> 1 -71 <br /> IP Code Time In .Out <br /> Business Rep Title i / -.�....., O AM ... ._ 3 . . ..,. C) AM <br /> } <br /> L O PM O PM <br /> Q._. <br /> �t1t ... <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire'Count (VllholelPTE ( (Fill one only) (Fill all thatapls,) (Fill all that apply) (Fill all ghat�npply} <br /> al <br /> i Q Active (7 P er 0 Generator 0 Ourtdoor <br /> E 0 Q Closed Q-Altered <br /> Latitude <br /> GP$ O Hauler 0 Indoor <br /> Q Inactive 0 Truck <br /> Longitude ( j 0 End-Use 0 Container <br /> I 0 Planned 0 OTR <br /> 71— ... ' lam_. .._- <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder Q 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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m FTI / m <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 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 0 Referred I CIWMB Enforcement <br /> Q 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 7` <br /> } ter - Ia <br /> Inspection Form Included: 0 � <br /> "I <br /> Comments Included: 0 <br /> P <br /> Business Rep's Signature Phone Number Inspector's Signature,, Phone Number11, <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® incorrect: XzE XIA 1i l i <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEAS <br />