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Waste Tire Sur0y & Inspection Report onspection Report Number ■ <br /> 3371.✓ State of CaliforniaC1WMB 181 04/04) - - - <br /> Cahfomialnt grated WasteeManagement Board Survey Form - Page <br /> Part A Survey BLUE OR BLACK INK PEN <br /> 13 s<P -- - apectott i�Qtls <br /> Y — tlna x x t is . <br /> TPI <br /> Site - Inspection Type (Fill one) <br /> Site Suffix: �' J <br /> Routine Q Re-inspection Q Referral Q Observation <br /> -.Local - -.. - __ _ _ - <br /> y / If Referral,choose referral type(Fill one) -" <br /> Identifier: l ( i [ � C' ( t Yr1 '!{ v�-[ .` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> _ P - y Inspector <br /> Physical Address <br /> . a� <br /> Street Q 1 CCi C <br /> L __f F,.l _ _ { �`) �� J Inspection Date r" <br /> City State Zifa Code Time In Time Out <br /> LD <br /> _I1 <br /> BusinessRepTitle 0 AM <br /> _ O PM �.�_J [___ <br /> . 'Y O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fillone only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> LJ <br /> e O ® Closed Q Altered <br /> GPS Latitude .�Q L.`�Q ! Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all that 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 <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 LE 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 /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> Q O Other: § <br /> Comments ,(��.) r i. C( � (t dl G+ f't r -!` ✓ y� t �`Ll r ( ' f ', <br /> .1 (f <br /> 0rF <br /> ' � Lji t��4lh ��Ct`o.,v.�. Tire (,.'o 1W L"( S 1('q <br /> Inspection Form Included: Q <br /> Comr As Included: Q -- - <br /> Business Rep's Signature Phone Number Inspector',s Signature Phone Number <br /> �_ .1. _ 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X I F"Q <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />