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Waste Tire S 4&y & inspection Repo,% Inspection Report Number s <br /> Ea"i. State of California <br /> g�� Survey Form - Page 1 <br /> `kR ,, CIWMB 181(New 04/04) '_- - <br /> California Integrated Waste Management Board <br /> Part A- BLUE OR BLACK INK PEN <br /> Survey <br /> Business.Profile _ 4i Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix � ��jj gg Q Routine Q Re-inspection Q Referral Q Observation <br /> — — —tlLocal If Referral,choose referral type(Fill one) <br /> � .�' <br /> Identifier: ��p..:I7.L F1 ��-� e v „ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> `1 _ <br /> 1 <br /> 14L Physical Address -- —� <br /> lie A- IJ <br /> >riPt>t <br /> Inspection Date t [C 1—sl <br /> L --) — e In Time Out <br /> tarty ,Stafe !F'f�`ocJe Tim — -- <br /> Business Rep Title O AM l 0 AM <br /> 0 PM ?I .. 0 PM <br /> �;. <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)'i (Fill all that apply) (Fill all that apply) <br /> Ttre Count(Whole�PTE) <br /> ActiveQ Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude d-- Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> f � <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 I 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 Ffl / 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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q IQ 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 /> 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 'X+A <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />