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Waste Tire Su & Inspection Report* Report Number ■ <br /> LIDIDe 3:, State of California " .may c j <br /> G R CIWMB181(New04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board J .�J _ ._. <br /> Part A Survey � � BLUE OR BLACK INK PEN <br /> B sin�ss f"fafri � I Inspection"b6tai�ls <br /> ELI <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: > EU, (jo Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1 ¢ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address �^ T 1-dEl <br /> – LL611-11 <br /> L— <br /> Street <br /> Inspection Date 5 r- <br /> City State Zip Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> Q PM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> -Latitude 0 Closed 0 Altered <br /> GP$ <br /> II-TIO <br /> 0 Hauler D Indoor <br /> 0 Inactive 0 Truck End-Use Container <br /> Longitude – 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> I <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> O O14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 014 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: 0', <br /> Comments Included: 0 _ - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ,N 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X , M p l 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />