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Report Number <br /> � Waste Tire SurelyOnspection& Inspection Reportp � <br /> ®� State of California - :� q ? '� ` <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I a I �' } U <br /> California Integrated Waste Management Board - - <br /> Part A- Sur ley BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ^ .� - <br /> Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> � J _ <br /> /Street <br /> Inspection Date 77-1--1--1 <br /> 1— _ <br /> • _ P [1—I] <br /> Business Re Title IP Code J Time In Time Out; <br /> Rep -— __.___. ..,._ . <br /> F- 0 AM <br /> Cit State Z <br /> -- -- ___ 0 PM _,.._ � .__,._. _ O PM <br /> 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 /> OMEN Q Active Q Passenger Q Generator Q Outdoor <br /> O i Q Closed Q Altered <br /> GPS Latitude ��� , -� Q Hauler Q Indoor <br /> PPo 3 Inactive Q Truck <br /> .=. -.. <br /> - <br /> Q Planned OTR <br /> Q End-Use Q ContainerLongitude QFTT .! <br /> Business Type (FIII all#hat apply) <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 HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 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 /> Q O --- - -- <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 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 Q In Compliance No.Violations <br /> Q 0 Other: § ----- <br /> Comments <br /> Inspection+orm Included: Q� <br /> Comments Inclutled: Q -- _ <br /> Business Rep's Signature Phone Number w rl ertcar" Si n t re Phone Numb r <br /> "!'+ °'. FELI, I T-IT —._�, 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: , I, + , .L <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� ■ <br />