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� z <br /> Waste Tire Su4by & Inspection Reporiilnspection Report Number <br /> State of California ;ew 04/04) i - — <br /> CIW <br /> Cahforma Int grat d WasB 181 Ne Management Board „Survey Form - Page 1 g '---' j <br /> Part A- Surve <br /> BLUE OR BLACK INK PEN <br /> r n$peCldt7 het 11S <br /> TPID- r - 0:1 <br /> Inspection Type (Fill one)L Y f - -- s�•� <br /> Site Suffix: ( ; - Q Routine Q Re-inspection Q Referral Q Observation <br /> .Focal ����-----���------ � - -- -.._ <br /> j I If Referral,choose referral type(Fill one) <br /> Identifier: <br /> I:,- f t{x ( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -- <br /> t~ -t I Inspected By Inspector <br /> Physical Address <br /> Stres't- / r <br /> • , Inspection Date <br /> [QE <br /> city - / Sfate ZIP C' <br /> Time In Time Out <br /> Business Rep �tf1 C.I 1( 1" Title I---(-___. - l 0 AM I 1 0 AM <br /> i IL., �__ J 0 P M 1_ _J 0 PM <br /> NMI,; 01111101Operational Status Business Role hfiorage;Type <br /> � (Fill one only) (Fill all that apply) <br /> re ot�nt�Wh�a � � a <br /> Q Active Q Q Generator <br /> ' _�_� E <br /> -- - J_j O Q Closed Q"tn ri <br /> GPS Latitude - Q Hauler or <br /> O ® Inactive Q' <br /> Longitude ; 'iJ-7 <br /> Q Planned Q'�" Q End Use Q Container j <br /> r�iasrness Type' '(�Illtell'th`�tt i��?� r" ,'- �„-�, „r'^-.-�—_-r--"v R,•., war,�, ."� - H x« <br /> Q New Tire Dealer Q Auto Repair ®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 <br /> 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 mm / 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 (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 f 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 /> Other: <br /> Comments <br /> t x.. <br /> LA 11_. <br /> � �� rl:dtl ,fitf Itr f ,'( o { <br /> 's-p-_ <br /> __ ._I1t.�_° <br /> Business Rep's Signature Phone`Number Inspectors,slgnature drone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X "� � ��6 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />