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Waste Tire Suity & Inspection Reportt,spection Report Number <br /> i _ <br /> EO�ar' State of California <br /> CIWMB 181(New 04104) <br /> Survey Form - Page 1 n <br /> a j f <br /> California Integrated Waste Management Board <br /> Part A- SurveBLUE OR BLACK INK PEN <br /> Xg _ _ <br /> i i: <br /> wBuslness F�rofri j..lnspection Details <br /> TPID- i Inspection Type (Fill one) <br /> Site Suffix: �; / j s ( ' Q Routine Q Re-inspection Q Referral Q Observation } <br /> Local ! _t f I -,—' ' -- -- <br /> If Referral,choose referral type(Fill one) <br /> / <br /> Identifier: / ,. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / <br /> Inspected By Inspector <br /> r <br /> Physical Address f <br /> Street Inspection DateIEL U <br /> I i^ i. l :' <br /> City State ZIP Cade Time In Time Out <br /> Business Rep -. Title i O AM j [ T <br /> PM � 0 PM <br /> L ow <br /> Operational Status tie? ype ) Business Role <br /> Tire Fount(Whole/PTE) (Fill one only) "u " ply) (Fill all that apply) <br /> =7 r <br /> Q Active er Q Generator <br /> GPS Latitude O Q Closed Q <br /> Hauler <br /> -.._. _._._ ��- _ -_ O Q Inactive <br /> LongitudeQ— P Planned Q End-Use <br /> C <br /> Business Type (Fi)f{ t a <br /> 0-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 <br /> HAULING AND MANIFEST REQUIREMENTS <br /> Q Q 'PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 m / m Q <br /> Q 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 a 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 /> 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 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments I <br /> T`-7 <br /> Inspection Form Iuded; QI ,l , <br /> A <br /> ncl <br /> Comments Included: " - -- ) ; 4 _. <br /> Business Rep s Signature Phone Number ISignature Phone Number ; <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X ,� l :X��,} J i� I_J F j 1 y 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® 0 <br />