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Inspection Report Number <br /> Waste Tire Suy & Inspection Report <br /> 61.21,111State of California I - A A — <br /> CIWMB 181(New 04/04) Survey Form - Page 1 a ° <br /> I _ r <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Bdsfness Profit Inspection C�e4all , <br /> TPID r Inspection Type (Fill one) <br /> LL <br /> Site Suffix L/ <br /> 111 (6 Routine 0 Re-in'spection 0 Referral 0 Observation <br /> Local - - <br /> If Referral,choose referral type(Fill one) <br /> Business or Facility Name c 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> - - - <br /> Inspected By Inspector <br /> Physi <br /> C <br /> cal Address _ - ! ____ <br /> Street <br /> Inspection Date <br /> LT___1 <br /> E <br /> i <br /> City T. State Ztp Code Time In _ Time Out <br /> Business Rep Title f rr 11L QAM H 0 PM _T] 0 PM <br /> �.I Operational Status Business Role S#oraeType <br /> (Fill one only) ( r)k s th f,n �j}' (Fill all that apply) (Ft11 SII chat apply <br /> 0 Active [ ;I�assenger. 0 Generator Outdoor <br /> 0- <br /> Latitude I 0 Closed 0 Altered, <br /> GPS T^ - 0 Hauler Indoor, <br /> - - 0 0 inactive (:Truck <br /> Longitude 0 Planned D OTIC End Use 0 Confamer <br /> "", ii�ss Type �Flll aI•t(i�t ap�lY�; �_ <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 0 Agriculture 0 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 /> 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 /> 00 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 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> -- - -- - - <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/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 <br /> 0 in Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: 01 <br /> Comments Included <br /> O re P_ . . n <br /> ho - ... <br /> Business Rep's Si natueiNumbee Ijnspectr s Signature"fit ,) Phone Nymber <br /> _ p -- - _, <br /> -- <br /> INSTRUCTIONS ON BACK Correct: incorrect: , ✓ 62081 <br /> X � TT� 9 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />