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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> era State of California 11 - 1143549 <br /> CIWMB 181(New 04/04) <br /> Survey Form - Page 1 <br /> California -- <br /> Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A_-_Survey <br /> - - - - <br /> Business Profile Inspection Details <br /> TPID- /J Inspection Type (Fill one) <br /> Site Suffix: a _(_ I® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ccx_pfv Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business Facility Name <br /> us or Y _ Inspected By Inspector <br /> 1e�' <br /> Physical AA"t✓ 4m <br /> no-1 _ —- - -- <br /> Inspection Date / QJ <br /> /'A <br /> Q_ Time In 0 AM Time Out v <br /> Business Rep Title <br /> � l AM <br /> rV�iC �.Yrt� � ' "j I ® PM �- 3 O O PM <br /> _6jeLLIVIe, _1. 6.� ti 1 -- - -------- -� ` `{- ,---- Operational Status Tire Type Business RoleStorage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active ® Passenger ® Generator ® Outdoor <br /> PS Latitude ® Closed Q Altered Q Hauler Q Indoor <br /> G <br /> 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 ® 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 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> 00 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q <br /> 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 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 In Compliance - No Violations <br /> Q 0 Other: § -- - <br /> Comments <br /> W <br /> Inspection Form Included: <br /> Comments Included: -- <br /> ® Busin ss Rep Signature Phone Number *Co' <br /> Phone Number <br /> -- ---- — -_- 6208INSTRUCTIONS ON BACK Correct:* Incorrect: X � 111 2t� <br /> ■ : ■ <br /> White Copy:CIWMB Yellow Copy:Operator <br />