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■ t'r Waste Tire Su&y & Inspection Reportiinspection Report Number ■ <br /> State of California %� -- ������0 <br /> CIWMB 181(New 04/04) � u rve Form - Page 1 I 1 - _ <br /> California Integrated Waste Management Board Y g <br /> Part A- Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 19-h <br /> C j Inspection Type (Fill one) <br /> Site Suffix: 3 � t tQ Routine <br /> Q Re-inspection P Q Referral Q Observation <br /> Local \ If Referral,choose referral type(Fill one) <br /> Identifier: 1 �c j y l� ���;}' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Ll <br /> Inspected B <br /> P Y Inspector <br /> l/� [a <br /> Physical Address <br /> Street <br /> ,r Inspection Date <br /> Carty State ZIP Code Time_In Time Out <br /> P Title Q AM Q AM <br /> Business Re I T,, <br /> / Q <br /> N ,Z/ O PM � 40 PM <br /> n - --- - -._t Operational Status Tire Type Business Role Storage Type <br /> =Tire Count(Whole/PTE) I 4-- � (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> {' ' ✓� Q Active Q Passenger 0 Generator Q Outdoor <br /> GPS Latitude - �o Q Closed Q Altered <br /> Hauler Q Indoor' <br /> _F TEQ Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container- 7 [11' <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 /> (3 Used Tire Dealer . Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Service Station l I r <br /> Q u e Q AgricultureQ Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility LENJIFORCEMENT STATUS___ <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q I PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 EX7) <br /> Q Q j 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 <br /> Q'In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> 11 <br /> Inspection Form Included: Q - fs <br /> Comments Included: ® > ..- .. ._:__.:,..._ —_. IB esiness Rp's SignafLre Phone Number Insp c or's Sigre Phone Number <br /> _ Xc -- . <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> { } A'fit P l- E <br /> White C 1 <br /> � ■ - - _ © ■ <br /> opy:CIWMM B Yellow Copy:Operator Pink Copy:LEA <br />