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Waste Tire SuW_y & Inspection Reportf Inspection Repo>r Number <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 - 1127637 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business ProfileInspection Details <br /> TPID- �. � -..I Q � Inspection Type (Fill one) <br /> Site Suffix: QRoutine QRe-inspection QReferral QObservation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: +� �(�} y` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical AddressEli Jere <br /> � <br /> ('Or r' G l l� J 1 c}►� �c� <br /> ..._. ______. _ �_____m:_ __ ___.._____ ._._._ _.__ _ _ _____._ _ <br /> I r_ <br /> Streef � /j � � Inspection Date <br /> If(" o t r S J (� <br /> . a ' <br /> Time In Time Out <br /> f�,e IYu=� _., <br /> i <br /> Business'-Rep Title O AM O AM <br /> A /`� <br /> ! Z A—TI V _' O PM QPM <br /> rA u'rJi��0r - <br /> Tire Count `W(2t�lel r- <br /> .......... _._ Operational Status Tire Type Business Role Storage Type <br /> I 1 f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (. P T ) ) <br /> Q Active } rIassenger Q Generator 0 Outdoor <br /> Latitude 10 Q Closed 0 Altered <br /> GPS Q Hauler Q Indoor <br /> �..._.-.�...+� Q <br /> .. Inactive Q Truck <br /> rllC'K . . <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type {Fill all thIit 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other (•t'�<��i f r;ih V!�h <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 <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/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> CCR§ 18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q 14 - an <br /> Q In Compliance - No Violations <br /> Q Other: § <br /> Comments <br /> jq 07L <br /> Inspection Form Included: <br /> Comments Included: <br /> BMstn�:ss Rep's Signature Phone Nu+ober Inspector's C39natur= Phone NaAmber -., <br /> �r� 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X "Y �i A M �r <br /> _ _� _A ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />