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Waste Tire Sulky & Inspection Repori0 Inspection Report Number <br /> iiI State of California 9 <br /> "" CIWM6181(New04/04) Survey Form - Page 1 I _ ! 1 6 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br />� TPID. t.-I Inspection Type (Fill one) <br /> Site Suffix: o Routine Q Re-inspection Q Referral Q Observation <br /> Local c TQ , Referral,choose referral type(Fill one) <br /> Identifier: Qf <br /> CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector - <br /> i r�n DkAW- Pb u� rg I _ <br /> Phys-ical Address Ti <br /> l <br /> Street � N t_�CinP <br /> Inspection Date <br /> I V'� \ C.A gISS G 6 l V lJ <br /> (`ity� Sate .ZIP ode Time In Time Out <br /> Business Re LLI : Q AM r � Q AM <br /> P Title <br /> Q PM ' QPM <br /> - - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that aPPIY (Fill all that apply) (Fill all that apply) <br /> y <br /> Tire Count (Whole/PTE) ® Active OPassenger Q Generator O Outdoor <br /> M ff: <br /> r--r-- <br /> Latitude O Q Closed Q Altered <br /> GPS I 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 /> 0 New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler 0 Agriculture Q Shredder ® Other prJu'-r%A Farm <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS - O Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / ELI <br /> Q 0 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 /> 0 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/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 Q In Compliance - No Violations <br /> Q 0 Other: § <br /> Comments Vin'i-16Cr*k clin --" <br /> OcAzri ��1► � � �May -T, �r �-� cP Q kc e <br />} re-t 20\A_� ick does- 04 n-Vo re_ ionk__4a-, no i <br /> - - - <br /> - - <br /> Inspection Form Included: Q' <br /> Comments Included: ( ; ', Y ;_ •. .. _._ <br /> Byis ness'Rep's Signature Phone Number' p9peetor's Signature* Phone Numb <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X Ak \ l:- as i A M!P 1 L i L, I 1 ; 2 13 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />