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■ jj Waste Tire Sufty & inspection Repor nspection Report Number <br /> State of California ■ <br /> CIWMB 181(New 04104) i r F R R _ <br /> California Integrated Waste Management Board Survey Form - Page 1 ®_. _ ' 1 - 4 <br /> PartA- Surve BLUE OR BLACK INK PEN <br /> usfnesrpfll'a,�. Inspection Details - — - <br /> :.... y <br /> TPID- ( Inspection Type (Fill one) <br /> Site Suffix. L ) �`_ C <br /> Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local j If Referral,choose referral type(Fill one) <br /> Identifier: r;ft 0 `j clef CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> _ ..... <br /> Business or Facility Name L <br /> Inspected By Inspector <br /> Physical Address ]�j _ _ (; ( t�Ltr`-i t L t_ /f' ._.•`,--% <br /> Lri <br /> Street <br /> f" Inspection Date <br /> ++✓ State ZIP Code Time In Time Out <br /> �- <br /> Business Rep Title- �--� , Q AM <br /> __ _. <br /> Q AM <br /> Q PM Q PM <br /> � <br /> Operational Status I Tire,Type` Business Role it Type <br /> fire COUnt 1lVhole/PTj (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply; <br /> ° � 0 Active 0Passenger 0 Generator 0 Outdoor <br /> I <br /> Latitude O f) Closed 0;Altered <br /> GP S <br /> LLJ 1 Hauler <br /> Ind o <br /> or <br /> 0 Inactive 0 Truck 0 <br /> Longitude - i � �! 0 Planned 0 OTR End-Use <br /> 0 Q Container <br /> Business Type (Fill all that ap"ply <br /> New Tire Dealer ID Auto Repair 0 Trucking Fleet Q Government 0 Retreader 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 <br /> ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST'REQUIREMENTS <br /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <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 IE / m / 11-1 <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 /> 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 1 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ° <br /> 0 In Compliance - No Violations <br /> 0 0 I Other: § —---- <br /> Comments S 1. A f1 f_ <br /> � U�� tGsCf DI<�r1E,� a� (20q.) 3 �/(� act �11i' } L/ 2 1/c/ 5( 4Ni�Gf <br /> Inspection Form Included. 0i k <br /> Comments Included: <br /> 0 Business Rep's Signature Phone Number tnspec"tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X q , +IIdIr 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> r <br />