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Waste Tire Sufty & Inspection Repor0 Inspection Report Number <br />•°•"� State of California <br />CIWM8181(New 04/04) Survey Form -Page 1 9. 1 0 0 i <br />California Integrated Waste Management Board _1_3_4 .... <br />'art A - Surve BLUE OR BLACK IN PEN <br />Inspection Details <br />TInspection Type (Fill one) <br />_�7, <br />PID - <br />Site Suffix: ff 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local <br />Identifier: <br />Business or Facility Name <br />, (' Ali <br />Physical Address <br />h <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Inspected By Inspector <br />Longitude <br />I <br />at apply' <br />0 New Tire Dealer 0 Auto Repair <br />0 Used Tire Dealer 0 Auto Body <br />0 Service Station 0 Hauler <br />0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Agriculture 0 Shredder (S Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />0 <br />r' <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />Street <br />PRC § 42956 - Registration/Decal in Vehicle <br />Inspection <br />Date <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />/ <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 <br />CitV <br />Business Rep <br />State ZIP Code <br />Title <br />Time In <br />/ 0 AM <br />Time Out <br />AM <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />/ 0 P <br />% <br />0 P <br />0 <br />I <br />Operational Status -e Type ---1I <br />Business Role <br />Storage Type <br />Pink Copy: LEA <br />Tire Count (Whole/PTE <br />I <br />I I I i <br />(Fill one only) <br />'� (Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />0 Passenger <br />0 Generator <br />0 Outdoor <br />O 0 Closed <br />0 Altered <br />GPS Latitude <br />I I I I I <br />11 <br />0 Hauler <br />0 Indoor <br />_I o I 0 Inactive <br />0 Truck <br />Longitude <br />I <br />at apply' <br />0 New Tire Dealer 0 Auto Repair <br />0 Used Tire Dealer 0 Auto Body <br />0 Service Station 0 Hauler <br />0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Agriculture 0 Shredder (S Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § <br />ner <br />0 Tire Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date <br />m / m / m <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />0 In Compliance - No Violations <br />Comments <br />- _— -1 r' t%/O%C L:G°Oat1° <br />J1 �•l/, i/��I �•i��� <br />/ l/P� � � tG <br />pM,r <br />Inspection Form Included: 0' <br />Comments Included: 0 <br />Business Rep's Signature <br />Phone Number <br />Inspector's Signature _ <br />Phone Numbe . <br />INSTRUCTIONS ON BACK Correct: <br />X X V ITIS—f TT1 62081 <br />Incorrect: }C A. ,�t P L 1 F 3 <br />White Copy: CIWMB <br />Yellow Copy: Operator <br />Pink Copy: LEA <br />