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Waste Tire Sui•vay & Inspection Report 'Inspection Report Number ■ <br /> State of California <br /> CIWMB 181 04/04) <br /> I 1 - 114 3 6 6 6 <br /> California Integrated Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey-_ BLUE OR BLACK INK PEN__ <br /> Business Profile 'Inspection Details <br /> TPID- 1 / g Inspection Type (Fill one) <br /> Site Suffix: J -2 0 r 0 Routine 0 Re-inspection Q Referral 0 Observation <br /> Local (� If Referral,choose referral type(Fill one) <br /> Identifier: G h — O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> `ate:... <br /> G - -=7 /3 1/ <br /> Physical Address �f ` <br /> 3u2.2 / f LC Gf iECt y�� 4t <br /> Inspection Date <br /> s 7 © 6 <br /> S74) r �� <br /> Time In Time Out <br /> Business Rep Title o S AM 1 / 40 AM <br /> " - OPM 0 P <br /> t✓ ----- - -- --- - -- — --- — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / 00 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O Q Inactive O Truck <br /> Longitude - 0 Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 0 Retreader Q Dismantler O 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 O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / m <br /> 0 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 /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/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 In Compliance - No Violations <br /> Q Q 1 Other: § <br /> Comments <br /> r <br /> `lei�/',� ¢.0 �e�f C� f-!�"•-C ti� i -�'� �`✓7 <br /> 40, <br /> Inspection Form Included: OI 7 <br /> Comments Included: Q - <br /> - Business I s ignature Phone Number - Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X X A L 112 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py: A ® ■ <br />