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Waste Tire SdW & Inspection Repor"nspection Report Number ■ <br /> ® '` State of California - Page 1 <br /> .,.Sy CIWMB 181 New 04/04) Survey Form <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> ''� t '^ �, ,,a ,Inspection Details <br /> Business Profile _ <br /> �. ,. w•, , , ,r .u,. ,,. <br /> T Inspection Type (Fill one) <br /> QQ L - Observation <br /> Site I uffix: I �� ! Q Routine Q Re inspection Q Referral Q <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: JC--� 1�'t.�'�kA 0A b`. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — Inspected By - - Inspector <br /> Physical Address �� <br /> 1 Street T ? _ Inspection Date MO <br /> J f <br /> �City Title- ��`�� �. �l�V� �f' State LIP C d Time In. Time Out <br /> __ O AM <br /> �__T70 AM <br /> siness <br /> Bu Re p � PM <br /> PM _. - — - <br /> I L - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply)' <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O 4) Closed Q Altered Q Indoor <br /> _L�_ <br /> GPS Latitude C I Truck. Q Hauler <br /> C� ��- <br /> 0 I Q Inactive Q Q End-Use Q Container <br /> Longitude - Q Planned Q OTR , <br /> Business Type (Fill ali that apply) <br /> 1 <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 1 A HAULING AND MANIFEST REQUIREMENTS 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 m <br /> -0- 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> Q Q 1 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Referred 1 CIWMB Enforcement <br /> Q 1 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q 1 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 Q In Compliance - No Violations <br /> 0 , 0 Other: § _ -- --- - _ <br /> Commentsf :i - 0 r <br /> f f j <br /> } <br /> Inspection Form Included:Q - <br /> Comments Included: Q Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ s 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X V I a+ � W �- I 1 + �' <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />