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Inspection Report Number <br /> Waste Tire SLOey & Inspection Repor ■ <br /> 6a$ <br /> m1. State of California j ..a CIWMB181(New04/04) Survey Form - Page 1 I <br /> California Integrated Waste Management Board <br /> Part A Survey BLUE OR BLACK INK PEN <br /> Rustrt ),Ilrtion <br /> TPID- + - - �] / Inspection Type (Fill one) <br />{ Site Suffix J. 2 C �' C 7 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local -W - if Referral,choose referral type(Fill one) <br /> Identifier: .��1 A} J �'� t.t w P_d C(•Oiv Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected By Inspector <br /> kA V f� - <br /> Physical Address I J l ( I �_. .� J <br /> j C: L) ! (�. • �/ Al rJ I I <br /> Street Lo <br /> (" Inspection Date [� 2 �� <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM V ��� 0 AM <br /> �..._, J � 0 PM LLJ I�_1 0 PM <br /> Operational Status Business Role Storce"Tfi s <br /> (Fill one only) (Fill all that apply) C (Fill all that apply <br /> ® Active Generator Q Outdoor <br /> _.._ ____. <br /> GPS Latitude ,1-1 .• pO Q ClosedQ Haulery Q Inactive t x' M'• <br /> D <br /> Longitude - `- -� Q Planned Q End Use <br /> Business type O til '• <br /> _QNew Tire Dealer QAuto Repair r Q Trucking Fleet ® 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 Other - <br /> A Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENNORe Of Violation AT S Extension <br /> HAULING AND MANIFEST REQUIREMENTS - - -- Q <br /> Part B - _ <br /> � V <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 /> M / M / m <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 /> 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 ii Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q i (Q In Compliance - No Violations <br /> Other: § -- ----- <br /> Comments <br /> A/III ' ! <br />{ <br /> Inspection Form lncludetl Q ° <br /> Comments Included Q <br /> = --- <br /> Business Rep' Sign re;= Phone Number Inspector s Signature Phone Numbe <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 'I, -_ IE X A*PWE1 f 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> 4 <br /> z <br />