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Waste Tire Su y & Inspection ReportInspection Report Number ■ <br /> State of.California ] "7 w n - <br /> ��� <br /> CIWMB 181(New 04104) Survey Form - Page 1 @ I ' ; 4 f ' <br /> California Integrated Waste Management Board -' -- ' - --- - e -- <br /> Part A- Survey <br /> y� BLUE OR BLACK INK PEN <br /> �iBG$InE36;P1brl :»; — , r ectf n � � � �7 .ars <br /> TPID- Inspection Type (Fill one) { <br /> I Site Suffix: <br /> - �- J. ' C) Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �' t;+.a� r ,, t- 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Physical Address <br /> Street <br /> f Inspection Date <br /> . <br /> l ate. 'A <br /> City -k Stage ZIP Code Time In Time Out _ <br /> Business RepTitle 1 AM Q.AM <br /> PM EES Ll ® PM <br /> t o rr.— <br /> Operational Status ^ pe Business Role <br /> (Fill one only) (Fill all that applVY�Vy) m, <br /> Ire pure' Noma <br /> d <br /> �HIM � , ® Active �, ,• (j) Generator <br /> D 0 Closed (�Alfeled <br /> 0 Hauler <br /> GPS Latitude ' 0 ii�d'bar <br /> •�_- _. 0 0 Inactive <br /> Longitude0 Planned 0 End-Use tib <br /> Business Type (Ftll all thdt y ; Isms <br /> 0 New Tire Dealer 0 Auto Repair Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 0 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 ' 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 -- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (Din Compliance - No Violations <br /> 0 0 Other: §. <br /> Comments <br /> `t r f <br /> Inspection Form Included. <br /> Comments Included: 0 - <br /> Business Rep's Signature - Phone Number Inspector's Signature T Phone Number _} <br /> INSTRUCTION - - - - — _ --- <br /> ..._i_ �...��.._ ._..1 62081 <br /> S ON BACK Correct: Incorrect X ,X <br /> MWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� ■ <br />