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Waste Tire & Inspection Re Inspection Report Number <br /> : - ` Y p <br /> 0•"`�' State of California I -.._J_ -Q.1-8--0­ 7 <br /> _�__...__....-_ -.__._..._._.----. ■ <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> 1 i1 8 V T 4 <br /> California Integrated Waste Management Board ___ _-. - i <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile <br /> 1 <br /> TPID- Inspection Type (Fill one <br /> Site Suffix: �- <br /> _/ -J L <br /> Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: }„t <br /> 0 CHP Q CIWMB Q Complaint 0 Educational Visit O Other <br /> Business or Facility Name - <br /> ::l Inspected By Inspector <br /> Physical Address ILL ' <br /> Stipel <br /> Inspection Date <br /> I=, <br /> / 40 / I t <br /> City State ZTp Code Time I_n _ Time Out <br /> Business Rep Title — T Q AM � 1 Q AM <br /> �_L _�QPM — - �[ QPM <br /> Operational Status �r <br /> Business Role <br /> (Fill one only) � Fill all that a Fill all that a I <br /> k t ( pP y) ( pp Y) <br /> Active t��f+ itj9i Q Generator 0 Outdoor <br /> O Closed <br /> GPS Latitude „t � � <br /> ° 0 Hauler 0 Indoor <br /> - Q Inactive <br /> O <br /> Longitude - O 0 ' <br /> Planned End-Use <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repan Q Trucking Fleet O Government O Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler Q Agriculture Q Shredder O 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Notice Of Violation D Extension <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / IE / III <br /> 0 Q 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 Q 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q , 1,4 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> Com,mefits p <br /> - - _ -' i �/g .. - 1:',T,Y•�.'. C' t'� t` J 1n�t, ��:__- t n "1' ,... .1 i ^_. <br /> ----------- --- -- -' <br /> Inspection Form included: 0' — <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: , i <br /> 62081 <br /> t`(,■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />