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Waste Tire S & Inspection Reponection Report Number <br /> y <br /> ■ ,r;4 state of Califorma - <br /> 6;c3. E CIWMB181(New 04/04) survey Form Form - Page 1 I 1 - 1088480 <br /> California Integrated Waste Management Board ) �7 <br /> Part A-,Surve- _ BLUE OR BLACK INK PEN <br /> „ , �„ x. <br /> ;p d ":' Inspection Details <br /> Buslnec � <br /> TPID- �) Kf Inspection Type (Fill one) <br /> Site Suffix: ' B ! 1 ��-1P- � Routine Q Re-inspection Q Referral Q Observation <br /> J Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address I i �) i <br /> Street <br /> Inspection Date �10 E I <br /> L_.-.- 1-- -'''� S Time In Time Out <br /> GSty _ Mate Z! Cade - --_J �LJ J 0 PM <br /> ._.�- <br /> Business Rep Title 1 AM j, 0 AM <br /> 0 PM <br /> Operational Status Tire Type Business Role Storage 7' <br /> ?Ire Count(Whole/PTE) ! (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that appiy <br /> i <br /> Active Q Passenger Q Generator Q Outdoor <br />�� r a ,a i ,rod a� �x��• - <br /> " <br /> 77-77 i--� i O Q Closed Q Altered <br /> Latitude <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q 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 <br /> Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 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 <br /> Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> — —- tib,,„; — ,,✓” �, <br /> Inspection Form Included. Q, p <br /> Comments'Included: Q; ---- - a' . ,a <br /> Business Reps Signature Phone Number Inspectors Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X �_ L E 1112 3 <br /> eWhite Copy:CIWMB Yellow-Copy.,Operator Pink Copy:LEA <br />