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t ` <br />Waste Tire Suy & Inspection Report; <br />£ Inspection Report Number <br />&�tYx State B California Survey <br />C m -Pagel r 3 iJ�i Aj }/^t� R <br />9ri:r� CIWMB 181 (New 04104) F 1 1, . f & 1 L f 3 6 5. V�- <br />California Integrated Waste Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />} TPID - - - Inspection Type (Fill one) <br />Site Suffix: (E) Routine .0 Reinspection Q Referral Q Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: rU_z t 1�r' � -<y �0 CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name _ ll I Inspected By inspector <br />I f, <br />Physical Address <br />I® <br />Street U <br />City. State ZIP Code <br />Business Rep Title <br />f <br />it <br />Tire Count (Whole/PTE) <br />s L.TJ�JI e <br />Inspection Date ^• <br />Time In Time Out <br />Q AM Q AM <br />`1 S Q PM �� O PM <br />Operational Statusl Tire Type Business Role Storage Type <br />(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br />© Active Passenger Generator Outdoor <br />f D Q Closed Altered <br />GPS 1 Latitude <br />m O Inactive 0 Truck <br />O <br />��':Longitude . - O Planned 0 OTR <br />f <br />Business Type (Fill all that apply) <br />New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader <br />Q <br />Used Tire Dealer Q Auto Body Q Car Dealer Q Collection - Q Crumb Rubber <br />Q <br />Service <br />Station Q Hauler Q Agriculture Q Shredder 0 Other <br />Part B - <br />Inspection of Waste,Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />0' <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />0 <br />PRC § 42953 - Contracts with Registered Wasfe Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />0 <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Lpgs within 90 days <br />O <br />O <br />14 CCR §18459.3 - Retention of Manifest Forms and Tire Trip Logs fora years <br />O <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />O <br />14 CCR § 18462 - Manifest System'Requirements for Tire Dealers or Waste Tire Generators <br />(� <br />(� <br />Other: § , <br />0 Hauler <br />F <br />Q End -Use <br />0 Indoor <br />Container <br />Dismantler Q Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date <br />m/m/m <br />j (Required for NOV or EXT) <br />Q Referred I CIWMB Enforcement <br />Q In Compliance - No Violations <br />Comments <br />�l1' <br />?' % �'tZ->� r rf/lc�dr <br />k /fit J %�=�/%� /�'i�/ �/� `!/., l; •! -�%��_ <br />i� 1-r- ' � %`.,.�� � • /` y!= . �r ,;�` • /' ��/l ,?r/� , ''f :fir_ �. ;.' � f� f' ,�' ' , ` . ` ., ��-` <br />ll, rrri 1d.< 1..� �G/''r.�/� ` �r j <br />Inspection Form Included: 0 <br />Comments Included: 0' ' <br />Business Rep's Signature Phone Number / Inspector's Signature <br />'I','—INSTRUCT(O7 S ON BACK [Correct:0 Incorrect: X <br />■ White Copy: CIWMB Yellow Copy: Operator i` Pink Copy: LEA <br />62081 <br />s <br />"Y <br />