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Waste Tire S & Inspection Repo <br /> ;_ y � p p ,Ilnspection Report Number <br /> State of California 1- <br /> CIWM618,'(New04/04) Survey Form - Page 1 9 - 1 0 �� � � Q 6 <br /> California Integrated Waste Management Board -- -- -- - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> a " y�""�'� r �t � �� +�" ' �t <br /> Business Profile ," bl� �)� 1 ( f �w b � � " (')wn w rtV f ti r <br /> .,.,. d.�5 .H+,u a.nK.wd��.~a a,,.s4..,ua_. Wi scrv:rt:-�.w._ <br /> TPID- Inspection Type (Fill one) <br /> (( <br /> i :; - :� <br /> f' Site Suffix: � l" J � � %.� 0 Routine 0 Re-inspection 0 Referral 0 Observation ' <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: + I)L;u- � 0 CHP � CIWMB � Complaint � Educational Visit 0Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ( - <br /> i <br /> Street Inspection Date [ / Cal,' <br /> C'itV State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0P 0P <br /> Operational Status Tire T e <br /> p yp R <br /> I Business ole Iwo- <br /> (Fill one only) (Fill all that apply); (Fill all that apply) <br /> Tire Count (Whole/P1 E) ° "'� '� k, <br /> ® Active 0 Passenger 0 Generator "t "U11111 <br /> O 0 Closed <br /> GPS (�Altered v "'ii �( 1 <br /> Latitude ' " <br /> 1�1 Hauler <br /> �"� �,� "� O <br /> Inactive4 <br /> 10 irf Y�tfOtfiGr ° wH) f} ° (year;% <br /> Longitude - 0 Planned 0 OTR fr �w R End-Use <br /> , n <br /> 0 New Tire Dealer 0 Auto Repair (a) Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/C:IWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments i. <br /> 1 t, <br /> �i-ii t L."�Jf< i. t�k.i�o ' y <br /> y tom' <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature _Phone Number <br /> -.-. <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />