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Waste Tire SLy & Inspection Report% <br /> Inspection Report Number <br /> L07'I State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 14 - 1 0 7 3 3 - <br /> California Integrated Waste Management Board ------- - - - - -- - - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> I�TPID : � Inspection Type (Fill one) <br /> Site Suffix1 � �' �._' r ® 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 77 <br /> Inspected By Inspector <br /> Physical Address fvt Ll, <br /> Street <br /> / Inspection Date <br /> City State ZIP Code Time In Time Out m <br /> Business Rep t Title (� : O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTM (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude W . Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)(T) <br /> ------------ <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive 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 /> i L•'i f i r';i iCl ( -1'M( <br /> f (i 1 it j" 1( 1 1 l '_(r�f C 1 (-tom IQ rLCr tr � ���.t� -l��l�uo�i1F� �(✓ f <br /> Inspection Form Included: Q' <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X /P \/ E Xi A M -' I_ f i <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� <br />