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Waste Tire S F Inspection Roporo Irection Report Number <br /> ��'- State of California <br /> _®i65i CIWM6181(New 04/04) Survey Form - Page 1 1 3 10 0 6 3 12 <br /> California Integrated Waste Management Board -- -- - - --- — --- <br /> Part A- SurveyBLUE <br /> OR BLACK INK PEN <br /> Business Profile <br /> TPID- p Inspection Type (Fill one) <br />} Site Suffix: l I rj L `- ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address _I I _ I I I , <br /> Street / FT-] <br /> / <br /> _ Inspection Date O <br /> City State lP Code Time In Time Out <br /> -- - — --- - <br /> Btasiness Rep Title ff � AM O AM <br /> 0PM H— 0 P <br /> Operational Status, aryt i° Business Role <br /> (Fill one only) � , , t �� (Fill all that apply) <br /> Tire Count(WholelPTE <br /> (jo A (3)ctive " �� �(� Generator <br /> ...,.A, wb kHrr r rt u w�h <br /> D ��` � ��U����� <br /> Latitude � Closed <br /> GPS Hauler <br /> 0 Inactive <br /> O <br /> End Use 4WLon etude 0 Planned <br /> �. <br /> .:r r ,n�'✓,:- „� N/� °*��"�yi�w i af^r�� 4 u��rM,�rte t �'�" ti r kr�J ,'r'�� l�re y�� Cw:Ir e m <br /> 50 <br /> ,.: y m e ,t,, ., , ',:;^ ; ,..;�, f;F, rr '�y u uSJ, a tr wu•; :..'r t ^r ' ;,M( brad t t iflt r"7> i >r. <br /> BU81 T �ih �, au r d r r �+aP+fi h r , "�h m�'�p I�� tw t � �� vl"YN �.✓�M „!4 � � �lrt w p"�.,,r P}a ,a, d <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel i <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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle m <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 (a)(b) (c)-Tire Program ID Number from CIWMB <br /> l 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 /> 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments ' (+ <br /> t <br /> ,, <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ t 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X i:, .," = i. I i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />