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Inspection Report Number <br /> Waste Tire Suiay & Inspection Repor p p _ <br /> �. , State of <br /> CIWMB <br /> 181(New 04/04) Survey Form - Page 1 5 - 10 14 8 7 0 <br /> '.- <br /> California Integrated Waste Management Board <br /> Part A Surypy BLUE OR BLACK INK PEN <br /> o fm r.. Y✓ d( / yea w yy P� r vK x',�y,+m, ti wa'm,(: 5 - <br /> C, <br /> 'IM, <br />} TPID- Inspection Type (Fill one) <br /> Site Suffix: W' f. O Routine p+Re-inspection 0 Referral 0 Observation <br /> Local �-- , s If Referral,choose referral type(Fill one) <br /> Identifier: O CHP 0 CIWMB O Complaint 0 Educational Visit Q Other <br /> ._:•� ,. <br /> Business or Facility Name "' Inspected By Inspector <br /> Physical Address <br /> Street ' <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> r 0PM m � m 0PM <br /> Operational Status )t r Business Role a <br /> �f, (Fill one only) (Fill all that apply) <br /> y (a Active Q Generator <br /> Q �dl alp �^ d , ltrru <br /> O Closed <br /> GPS Latitude <br /> two r eft rl r Q Hauler ? n r <br /> Q Inactive ��)/I/1� <br /> Longitude — 0 fr ) Q End-Use GCI" <br /> Planned <br /> ® New Tire Dealer 0 Auto Repair Q Trucking Fleet O Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Used Tire Dealer O Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station 0 Hauler O Agriculture Q Shredder O 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 0 Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR 18459.3-Retention of Manifest Forms and Tire Tri Logs for 3 ears <br /> § p 9 Y <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 Q 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 In Comp Bance No Violations <br /> 0 Q 'Other: § -- - <br /> Comments <br /> --f <br /> - 62081 <br /> Correct: Incorr ct ;K , 6= � �`�, � � � 3 <br /> INSTRUCTIONS ON BACK - <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />