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l <br /> H Waste Tire Su ;_ & Inspection Report F <br /> nspection Report Number <br /> State ofCalifornia <br /> CIWMB181(New04/04) urveyForm Page1I Z - 1 0 7 4 1 $ <br /> California Integrated Waste Management Board <br /> Part A- SurveyBLUE OR BLACK INK PEN.. <br /> 1 Business Profile Inspection Detail's <br /> T,PID- C- I Inspection Type (Fill one) <br /> Site Suffix: i Routine O Re-inspection 0 Referral Q Observation . <br /> If Referral,choose referral type(Fill one) ---- <br /> Identifier: fR ,. . O CHP . Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name {� f <br /> 1 r _ Inspected By Inspector <br /> Physical Address [JE J C) I lip'A <br /> yj C F/•(f r <br /> . QC/0 S VVI ! SCI1 0jo. tI , <br /> Street / <br /> Inspection Date <br /> tJrj l l 1. <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM m0 AM <br /> �n 0 PM m I�LJ O PM <br /> Operational Status Tire Type Business.Role Storage Type <br /> Tire Count �Whole/PTE 11 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)"� Active Passenger a Generator & Outdoor <br /> O Closed �` Q Altered <br /> GPS Latitude 01 1 nactive 0 Truck <br /> Q Hauler 0 Indoor <br /> IJ t <br /> Longitude – Q Planned ) Q OTR 0 End-Use Q Container <br /> x <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair O Trucking Fleet Q Government r Q Retr6ader Q Dismantler O Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection I Q Cru'm'b Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other I — <br /> ' Part B- Inspection of Waste Tire Dealer, Generator, Hauler.and End-Use Facility ENFORCEMENT STATUS--- <br /> V A ;HAULING AND MANIFEST REQUIREMENTS <br /> O Notice Of Violation O Extension <br /> O ; O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> I <br /> I <br /> O I O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O Q 14 CCR§18461 _Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance -.No Violations <br /> O 0 Other: § <br /> Comments I/'tL\ jr, G l 1 a Lt sd-I <br /> ff b <br /> 3 !1 N .t ( f"t c f t (+ ('/f✓ 1 "l�F I fJ C S o { ✓I(� () pti1,t`)Ci <br /> c ( t r <br /> r<k t,r0 0. <br /> I0, f l' Ct,/ rel ( fl <br /> Inspection Form Included: 0i <br /> Comments Included: Q'.-- { <br /> !Business Reps Signature Phone Number Inspector's Signature Phone Number <br /> — -- - --- 62081 <br /> INSTRUCTIONS ON BACK !Correct': Incorrect: (AtjEjXj.Aj0AjPp 1 .2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />