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Waste Tire Sy 8c Inspection Repo . Inspection Report Number ■ <br /> ..__ - <br /> �.i n <br /> Slate of Survey Form - Page 1 - 0 i <br /> :- CIWMB181(New 04/04) i <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile spe1AC +t�ly'^r°. <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> Routine 0 Re inspection 0 Referral 0 Observation <br /> � Local i �' -_-_� � � If Referral,choose referral type(Fill one) <br /> Identifier: i -. <br /> _ ^:' _ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical AddressStreet <br /> Inspection Date <br /> 20'41 JJ <br /> City- State ZIP Code Time In Time Out <br /> Business Rep Title O AM u 0 AM <br /> 0 P 0 P <br /> ` � Operational Status Business Role 1 <br /> Fill one only) r`f�, "r ' Fill all that apply) <br /> Active Q Generator <br /> D 0 Closed ) , <br /> Latitude l zk ar� P ) ,4 <br /> GPS � � 0 Hauler e <br /> L 0 inactive w #t <br /> � 't 5 <br /> Lon Rude — i14 0 End Use <br /> g � Planned r+"um <br /> „� ,w•-.. ..: w, r. °, �,,. �, r , ,ar..-:.,� w .r.�.� ,. ft..,.... s -,1( '",H° r, ro^ ,M;: d �, ,:�� r . .: .,� <br /> MAO r.,n:t:�.,.m ,.. .. ... 21111 <br /> &'b✓,Nf �a.."r. <br /> 1. <br /> 0 New Tire Dealer 0 Auto Repair @ 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 1. <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 -- 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 /> 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?CIWMB 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 <br /> 41 <br /> i <br /> Inspection Form Included <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ,F - ----- /� L i' 62081. <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: a/ ' :'on <br /> �� <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />