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Waste Tire 14*ey & Inspection Reps* Inspection Report Number ■ <br /> State of California t _ `l 7 ✓( '� <br /> i0s"Sn <br /> CIWMB 181(New 04/04) Survey Form - Page 1 - <br /> California Integrated Waste Management Board <br /> Part A- Survey_ ___. BLUE OR BLACK INK PEN <br /> ,Business Profile, _ _." _ Inspection Qetails <br /> Inspection Type (Fill one) <br /> Site Suffix: -1 �� � rfO Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �_.� GA u ytL�K h O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 5frd7t <br /> Inspection Date �� l <br /> L...✓_ _.U�1L �_/-�_."_"_.__. I — __".� � Time In Time Out <br /> Cr+ State Zip Grade Business Rep Title O AM O AM <br /> PM <br /> �ee let O 7v�. I [---TJ - - <br /> "�-- - ^---`- —--'""J —__.__.—j Operational Status lire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active O Passenger (5) Generator O Outdoor <br /> O Closed 0 Altered <br /> GPS Latitude O Hauler 0 Indoor <br /> - — � � O Inactive O Truck <br /> O End-Use O Container <br /> Longitude — O Planned O OTR <br /> Business Type (Fill allthaf <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station - Hauler O Agriculture O Shredder O Other <br /> Part B --inspection of Waste Tire Dealer, Generator, Hauler and End-Use-Facility ENFORCEMENT STATUS <br /> V A :HAULING AND MANIFEST REQUIREMENTS Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953 Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date t� M IE O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB / I <br /> O O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days -(Required for NOV or EXT) <br /> ® O - --- - - <br /> 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> i <br /> O O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 1 O In Compliance - No Violations <br /> O O Other: § <br /> Comments / !� / <br /> jtj <br /> r / <br /> V, a Ae A?: r <br /> 771 <br /> Inspection Form Included: O <br /> 1 r ''< k <br /> Comments Included: O - . <br /> Business` 'Business Reps Phone Number Inspectors Stgnatuf Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X /P '1 O A�M � EI. <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />