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Waste Tire ftey & inspection RepillptI& Inspection Report Number. ■ <br /> �i@*j State California I 1 - 1086967 <br /> ° 9 CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board Survey Form - Page 1 ------- - -- <br /> Part A- Survey -- - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: i Q Routine Q Re-inspection Q Referral Q Observation <br /> Local ��s f! _ If Referral,choose referral type(Fill one) <br /> Identifier: 1 (,{!,l!ti �l!>�i` ` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - Inspected By Inspector <br /> Physical Address — <br /> ` I( P <br /> Street <br /> j Inspection Date <br /> (---- — ! Time In Time Out <br /> city State ZIP Code <br /> Business Rep Title � 0 AM�.._ 0 AM <br /> O PM ��.� .. 4 Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> , <br /> � <br /> The Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all,fhat apply) (Fill all that apply) <br /> , <br /> ? QActiVYe r Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 7-7-7O Q Inactive Q Truck <br /> Longitude - O End Use Q Container <br /> Q Planned Q OTR <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 /> HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle m <br /> Q Q 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 114 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O ---- - - <br /> 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O ' 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> O O Other: § _ - <br /> Comments <br /> I <br /> inspection Form Included: Q "wT <br /> Comments Included: Q', <br /> Business Rep's "Signature Phone Number Inspectors Signature „ ,`'"' Phone Number <br /> - - - -- -/ - <br /> /\ � � _-� � 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: , � � A hh �' �. E 1 � � <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ y <br />