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Waste Tire Shy & Inspection Repo" Inspection Report Number <br /> State of California <br /> T�nia CIWMB 181(New04/04) Survey Form - Page 1 I 1 1127592 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details 1 ' <br /> TPID- i Inspection Type (Fill one) <br /> } Site Suffix i { <br /> Iq Q Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 r If Referral,choose referral type(Fill one) <br /> Identifier: t ( i (� ci t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> {) P y Inspector <br /> PhysicalAddress / t i - ��� � �S� _ C✓ <br /> � e <br /> €.. lr �..... _ ..__�..._.._ I <br /> eet <br /> Inspection Date '; 3 <br /> i t? Z{F,Cade Time In Time Out <br /> Business Rep Title Q AM0 AM <br /> 1 I - <br /> )j ��1 _�._. 1._ 0 PM t_. C�\ .� 0 PM <br /> J.-......_..._....... ..-... .= Operational Status Tire Type ype Business Role Storage Type <br /> Tire Count (Whole/PTE) I j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> O. � , :. y� i•� ( � d Active 'Q Passenger O Generator 0 Outdoor <br /> Latitude C Q Closed 0 Altered <br /> GPS 1 _ _ Q Hauler 0 Indoor <br /> ......... _.L._ _..,0 Q Inactive 0 Truck <br /> - <br /> in <br /> Longitude - l j Q Planned O OTR gj O End-Use Citalner <br /> Business Type (Fill all that apply)'' <br /> ONew Tire Dealer OAuto Repair O Trucking Fleet Government ORetreader <br /> O 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 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 <br /> -_- --- — -- - - 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 O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> A)�S \J i-I <br /> 111t�1 1 1 + 3 ;JI �j ( Ili t i'•��l��- -•�� <br /> Inspection Form Included: <br /> Comments Included: 0' <br /> Business Rep's Signature Phone Number inspecWr s Sigriabme Phone Number <br /> X <br /> -- <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X XA MIP 62081 <br /> 4 �I i <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />