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Waste Tire Sly & Inspection eporumerState of Repole Inspection Rt NbNo <br /> California �CIWM6181(New04/04) Surve Form - Page 1 ' , <br /> California Integrated Waste Management Board Y <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> )mMi �µhrr hf° g „�F,,� a °'a✓,d..�'�''�'� °' ',, ""��v vErVRa9 c.t ,w'�Nv. r,r,v,:, i„'r + "r"":xIn �"�:' <br /> �y`7� <br /> I TPID- � � P� h _ Inspection Type (Fill one) <br /> — <br /> ..� � ! � V f ® Routine Q Re-inspection Q Referral Q Observation <br /> Local %` If Referral,choose referral type(Fill one) <br /> Identifier: l G`( I / t <br /> 4 t;., Q CHP Q CIWMB Q Complaint Q Educational Visit Q,Qther , <br /> Business or Facility Name <br /> Inspected By, 0a <br /> Inspector <br /> Ph ysical dress — / FIT—Ad <br /> LA <br /> tA <br /> Street L <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title <br /> 0:1r � AM <br /> ! , <br /> L <br /> � ' U QPM [T : ' <br /> 1 —,J ® PM <br /> / f <br /> _j I „ ria rry <br /> Operational Status r �� tr � Business Role , <br /> L (Fill one only) � (Fill all that apply)Count(Whole/PTE) <br /> D Active " eQ Generator <br /> aY(r <br /> Latitude QClosed <br /> GPS r <br /> Hauler ���”' <br /> Q Inactive �� r yf° ME <br /> Longitude <br /> °v <br /> Lon <br /> g Q PlannedEnd- <br /> B"" <br /> nd <br /> �� / <br /> B[{;S�InST9 + �k°a ; 6/ rr"�yar �rr°ra rr ✓a yfr ti°° a ! Cny"Y i;, ° 'rrr rryar yr°av �M1"° <br /> ,.,�- S! aJ T;e;°r r*, h r f'y `�.. c.,y <br /> a {, <br /> Q NewTireDealer'. 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 Hauler Q Agriculture Q Shredder Q 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 /> — — -- 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / El <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <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 /> 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 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments f <br /> l(� W lo �.' I;. 'i f _ -1v ( �,)( A( A,)0 �' y i� ��.,�� f �t (°f(/F r��. I rf i2 4 �. <br /> f 1 <br /> rii f :.r ( C ! ;i ✓ _ ©jtP I/Ct.l �i'.A15J-r 67 k' It✓F,: inn (�( �[ { <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X X A A?, 62081 <br /> LlLl Ylitl�l <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA .: <br />