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IL Waste Tire S y & Inspection Repor , speation Report Number <br /> State of California ■ <br /> CIWMB 181( e ) Survey Form. - Page 1 3 1 $ . 'd $ <br /> California Integrated WasttManage <br /> Waste Management Board <br /> Part A_ Survey BLUE OR BLACK INK PEN <br /> ausiness Profile Inspection Details <br /> TPID- ! ` E <br /> Inspection Type (Fill one) �I <br /> Site Suffix: f ( l <br /> _� [� ] <br /> Q Routine Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C�(I t (jt_4{ (_l� t ` (t�(. v Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ' — — - <br /> Inspected By Inspector <br /> i 7c3Physical <br /> Address – <br /> Street / <br /> .} / 7� <br /> 9 f(if,-lc !t.E'1 �� ,J c;0 Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title QAM 0 AM <br /> tj EE • m0 PM m ' m 0PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) � (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f (9 Active Q Passenger 0 Generator Outdoor <br /> Latitude 0 Q Closed Q Altered <br /> GPS m • Q Hauler Q Indoor <br /> D Q Inactive (E)Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q2 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 (a Other } ( {^ <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> --- --.. ..__.__.._ — --... ......._....-. - <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> 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 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> / T7 <br /> Q Q 14 CCR§18459.2.1 -'Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> - ..-- -... . - ---- <br /> Q Q 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/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements.for Waste Tire.End-Use Facilities <br /> Q Q 14 CC1R§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Othie�{ `J Q In Compliance - No Violations <br /> (9 0Comments .it d rP(f t �Yf i YLd f1Q ' lU�lrht i2f, I ktrl(l ,UG rt. <br /> Q,l-�1 �.�l� loot (t-f; .All arc�1ry� �A,�crc nt,/ <br /> } �; r(�1 E'1l>7r �r�, aifd [i'!�`i`( fl,+ut r) 6,4f �� t�()Cf���r lly-rs. <br /> S VoredOn h l arOvt( erg oocI 55 'U-e .fly itr` /* <br /> Inspection Form Included: Q Ye <br /> Comments Included 0J, . <br /> Business Rep's Signature Phone Number Inspector's Si nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X)( 4 P ,� S ?� 62081 <br /> ■ White MB Yellow,Copy:Operator Pink Copy:LEA ® S <br />