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Waste Tire Su1W & Inspection Re Ort 7spection Report Number <br /> State of California 9 F, gf ■ <br /> GiGns� CIWMB 181(New 04/04) j <br /> Survey Form - Page 1 I f _. <br /> : =a, <br /> California Integrated Waste Management Board _ <br /> Part A- Survev BLUE OR BLACK INK PEN <br /> specton <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> 0 Routine 0 Re inspection 0 Referral 0 Observation <br /> Local r- -- - If Referral,choose referral type(Fill one) <br /> Identifier: J ;-'r r �:c,c:v, O CHP O CIWMB Complaint O Educational Visit0 <br /> Other <br /> Business or Facility Name --- <br /> ` - Inspected By Inspector <br /> — - --- <br /> Phy swat Address i' ) 91 /1 <br /> Street <br /> 7 r Inspection Date <br /> Ci(, "`, - State ZIP Code Time In Time Out <br /> Business Rep ` f itle I Q AM Q AM <br /> 0 PM 0 PM <br /> rfuf: .: f( r tt <br /> S^kuej'A v <br /> Operational Status Io Typs / Business Role ' o 21ge l`ype <br /> a d (Fill one only) FIII all,that apply}' (Fill all that apply) (Fit!alt that apply <br /> Tire�i�unt ; hoNe/�w + <br /> .,".r. <br /> 0 Active 0 Passeh,gpr,, Q Generator 0 Outdoor <br /> O 0 Closed Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> �'��'��`��' O <br /> Inactive 0 Truck g <br /> IM14 <br /> 0 <br /> Longitude f 0 planned ( OTR 0 End-Use 0 Container <br /> � . <br /> Business Type - <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 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 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VV I A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension' <br /> 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q 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 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 f CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 j 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> } 1. 1, t/r', ✓ r t'4+ ,' ��-�� - <br /> ?► '1/(�I `t� �> V I€�ir1�l'G�. �, .�� '?►'' ' . � !. � U <br /> 1lr is ✓t' (t,� rl (` L�( t r{t: FI ( )'t � � !'� 4 r2fF .� ✓ ( <br /> �� ( ( �C <br /> r <br /> i. MW <br /> ,a+a x �" „ r <br /> Inspection Form`(ncluded'c 0 <br /> Comments Included: 0L_ <br /> Business Rep's Signature Phone_Number_ Inspector's Stgnure Phone Number <br /> INSTRUCTIONS ON BACK :Correct: Incorrect ,: 'X i 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA S <br />