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Waste Tire Suoy & Inspection Reporialnspection Report Number <br /> -•GiSZi State of CaliforniaI - '7 /5 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 1 10 10 t_---�- 2 <br /> California Integrated Waste Management Board <br /> Part A- Survev BLUE OR BLACK INK PEN <br /> Inspection Details <br /> 1 _. <br />} TPID- O ' `1 Inspection Type (Fill one) <br /> Site Suffix: V V (DRoutine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: r) (, � �L) C7 C/:(,- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> " , Inspected By Inspector <br /> iU0 to <br /> Physical Address <br /> Street <br /> � Inspection Date C <br /> �— <br /> Cifv State ZIP Code Time In Time Out <br /> Business Rep TI I I 0 AM 0 AM <br /> Busi Title C <br /> 0 P 0 P <br /> Operational Status Tire Type Business Role orage Type <br /> - (Fill one only) (Fill all that apply)' (Fill all that apply) Fill all that apply) <br /> Tire Count (Whole/PTE) , <br /> Active Q Passenger (a Generator Outdoor <br /> O Q Closed Q Altered <br /> � . <br /> GPS Latitude O Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Container <br /> Q New Tire Dealer Q Auto Repair (3 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 <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Iti Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m m <br /> 010 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q O 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments I (( J <br /> C VylNEEF <br /> _------ <br /> Inspection <br /> Inspection Form Included. Q <br /> Comments Included: Q 1 <br /> Business Rep's Signature Phone Number Inspector's Signature „ Phone Numj <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X1�- � <br /> I/ E X A 14P L- E 1 2 3 5` <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />