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ka <br /> Waste Tire SLy & Inspection Reporinspection Report Number State of California e._._..I <br /> CIWMB181(New04/04) Survey Form - Page 1 <br /> S <br /> California Integrated Waste Management.Board - -- <br /> Part A Survey _ BLACK INK PEN <br /> BasttFI'rsaftle` _ _y._ Inspec $'. R ,,ry4 <br /> tion DLLetail <br /> Inspection Type (Fill one) <br /> TPID- Observation <br />' Site Suffix: � Routine Q Re-inspection Q Referral Q: <br /> Local - — x - If Referral,choose referral type(Fill one) <br /> Identifier: CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> T <br /> tom.; I <br /> Business or Facility Name ) Inspected By Inspector <br /> Y•I <br /> Physical Address J - ! L✓L._'_. $ /C J <br /> fit <br /> Street r <br /> rInspection Date ; <br /> city State ZIP Code Time In 0 EE 0 AM <br /> Time Out <br /> Business Rep Title AM <br /> O PM ' Lt I O PM <br /> 1__AU( d 4 ,1(j <br /> Operational Status ( ffe , Business Role ra eType , <br /> (Fill one only) (FIII all that apply (Fill all that apply) (Fdl all the apply, <br /> Q Active Q Passenger Q Generator Q,Outdtyor.< <br /> Q Closed Q Altered' <br /> GPS <br /> Latitude Q Hauler Q Indoor <br /> _ C Inactive Q TtuCk <br /> Longitude - Q Planned Q OTR Q End-Use Q.Container <br /> Business Type �FI)I aG that app <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 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 m / 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 I (Required for NOV or EXT) <br /> Q O -- - --- <br /> 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years I <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CI"d4MB 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 /> r T , <br /> C/ i <br /> fVit .- - - - -- -- <br /> ill id, tiiir Form'tnc dde <br /> Comments Included:.Q y <br /> Business F2ep's Signature Phone-:Number Via'ector Signature =Phone Num�bet <br /> - - —- - <br /> INSTRUCTIONS ON BACK Correct:* incorrect., 4 �Ir�: � - ? 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® . <br />