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Waste Tire Su4ef& Inspection Re ortopection Report Number <br /> p p <br /> ■ FAH Stateof California <br /> CIWMB181(New04/04) Survey Form - Page 1 I1 - 1140726 <br /> California Integrated Waste Management Board <br /> ?art A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: , I ��� ; 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J ��✓tY L ��l/1� — 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> oc CA,VA Avlm�- <br /> Physical AH ess <br /> 1 <br /> t I Inspection Date �r J <br /> Time In Time Out <br /> Business Rep Title 0 AM / 0 AM <br /> PM 0 PM <br /> - - Operational Status t Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Ay (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q-Active --- Passenger- 0 Generator0 Outdoor <br /> O 0 Closed 0 Altered 11-IIA <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer ® 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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FEINIFORCEMENT 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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> C'` \ //Or - t� �C�Ci �� !� Yj_Q_L�IyZ-.0 ✓ __ �JY-fit T�YLCa <br /> 41 <br /> I <br /> Inspection Form Included: 01 <br /> p 9 L� ! q e <br /> Comments Included: 0 lC&A0 ge_KC16Y -- --- - - - - - / g 6p ?e <br /> Business Rep's Signature Phone Number Ins or die Phone Number <br /> -- _ <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X (^ X1 A M rP _ E �f i 21 3 1 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy. �� ■ <br />