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Waste Tire Suoloy & Inspection Reportspection Report Number <br /> .-- ---_.-_.. --._- ._- <br /> W��."34� State of California .7 p8 <br /> CIWMB181(New 04/04) Survey Form - Page 1 U I I z I <br /> California Integrated Waste Management Board ____ _.- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j ,? Inspection Type (Fill one) <br /> Site f Suffix: t J j /r , +.J / `T + Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> - <br /> Street, <br /> " Inspection Date <br /> city State ZIP Code Time In Time Out <br /> Business Rep TitleF 0 AM Q AM <br /> [_L <br /> ' O PM O PM <br /> Operational Status Tire Type)",," Business Role Storage Type <br /> UYl (Fill one only) (Fill all that app (Fill all that apply) (Fill all that apply)' <br /> ;r <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude )e" Q Hauler _Q indoor <br /> Q Inactive Q Truck <br /> Longitude Q End-Use Q Container <br /> Q Planned Q OTR <br /> —--' <br /> Business Type (Fill all that a�ppzo.m <br /> ly) <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 1 ( / <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other I (_F h /Wt 7 1"/ �'�e"'t e ( !I1. <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFESTREQUIREMENTS <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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / FTI m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> ��' r)S(:,-va I r v (."1 �{�f ( i/► <br /> I (;? 0j oali 0 (/ E_I v V�t i �s}��( I!(ill V U f l �'L(7 y <br /> kitA- �l��ll �i�'-�9'1 C( 1C�+� � Iy(�_- '� rd r"F t uo <br /> be C, 'C' d 0V'bdlecjl itU t"� r� `1-01 et. r( � rxr e F �( Itir, L►t 1�;IG ' " ! "Ul <br /> inspection f=orm Included: Q' <br /> Comments included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X p ;, ;X,:A rii C I_y C,: 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />