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€��: Waste Tire S y & Inspection Repol 'Inspection Report Number ■ <br /> ■ HHHFH. State of California �. . <br /> HHHSH CIWMB181(New 04104) Survey Form - Page 1 I 1 8 - 1 0 3. ¢$ <br /> California Integrated Waste'Management Board t <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: m (d Routine (0, Re-inspection. Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: (/} b� /� ( Q CHP Q CIWMB .Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> FJ�c-f Tire / 1�)ravlYk0rA <br /> Physical Address o— ( je K vt,t'. .t Z <br /> ?S� AJ , l)IVJa� -- <br /> Street '� j t ' Inspection Date i t <br /> I <br /> v, t <br /> City State ZIP Code Time In Dom' Time Out <br /> Business Rep Title 0 AM O AM <br /> p �^ PM PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 0 y) ( apply) ( y) ( Pp(Fill one only) Fill all that a I Fill all that Pp a I Fill all that y)a I <br /> I�J (D Active Passenger Q Generator (E) Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m • Q Hauler Q Indoor <br /> QQ Inactive &Truck <br /> Longitude — t' Q Planned t OTR End-Use Container <br /> Business Type (Fill all that 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 &Other �lPr. (( t` G(Gif:(L claifc( I / <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m m <br /> Q Q m <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O .0 <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement b , <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 0 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments " <br /> Tj r T )q <br /> m Z �c of� . -!,; (allow -LA 10 �Cyft'� k;0( IT 2an(< i�'1'� PC' rC'„I CU <br /> fl' � <br /> t r <br /> octteAI (to,t FvivI,,Don,Ie,t �<<� <br /> fl i 'lit 1.1Q(u �?Y►i1�i�� Git�Gt 1_tVllE1 I✓�t�P77� �lCitlr+J►1 �r* >i/Gtt�f/� {}Ci 1 Gt�Q f�LW6r <br /> 0f P)(CA t10L'r! t d k iIUQ✓Q E t'��{f. �D t(`Y�-.; EDP o-,)d CV1� ✓P tJ1t)V I(�(C� — <br /> Inspection Form Included: Q <br /> Comments Included: 0': <br /> Business Rep's Signature Phone Number Inspector's'Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct. Incorrect:7X)( : NIP L � � ���� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> a <br />