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Waste Tire Sulay & Inspection Reporoonspection Report Number <br /> Waal <br /> State ofCalifornia <br /> CIWMB181(New 04/04) Survey Form - Page 1 it - 10 13 5 6 <br /> "'ifornia Integrated Waste Management Board _— - <br /> 81 <br /> Part A Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Saffix: i % I �� �� j rj j C! (D Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. / L r! r<(/1 is 0" , Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name i JC/ Inspected By Inspector <br /> Physical Address �• - <br /> - <br /> L <br /> f <br /> Street r. f Inspection Date ( ( f <br /> City j I State tsZIP Code Time In Time Out <br /> Business Rep Title0 AM EF 0 AM <br /> A I i � : L � Q PM m ' 0P <br /> E. <br /> - I Operational StJ(f <br /> ire Type Business Role Storage Type <br /> Tire Count (Whole/PT (Fill one only) ill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Passenger (3)Generator 0 Outdoor <br /> D Q Closed 0 Altered <br /> I GPS Latitude m . Q Hauler 0 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - I 0 Planned 0 OTR End-Use Container <br /> Business Type (Fill all that apply) " <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet Q Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station Q 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 <br /> 0 O 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / FF / 7 <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 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 0 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments C I�lT7 r1--e Iv, -!' t ;)'- -f t i I _ J.t-( f <br /> Y r <br /> 9 C 1 � <br /> Inspection Form Included: ^ <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �'�� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X TA 0A P Z �' 3� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />