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Waste Tire Su&y & Inspection Repor Inspection Report Number ■ <br /> •��H State of CaliforniaCIW /'y <br /> B 181(New 04104) <br /> California Integrated Waste Management Board Survey Form - Page 1 t V - 10 13 0 9 3 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> il,r. b#ile Inspection Details <br /> TPID- i; �, f r j� J Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: {, ( . E ,it t I'jt� yl Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> r <br /> Physical Address f t ,11 1 L <br /> ri y1 $ , t_ LtI - <br /> ivI <br /> `- <br /> Street6�9 <br /> t Inspection Date <br /> City State ZIP Code Time In Time Out 0 Am <br /> Business Re0 AMp Tit FL_ L.__.. 0 PM ' FT 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)) (Fill all that apply) (Fill all that apply) <br /> Tire Count(`hole/PTE) t <br /> Q Active Q Passenger �;, Q Generator Q Outdoor <br /> Latitude O ® Closed Q Altered i <br /> GPS EI • El_ _ Q Hauler Q Indoor <br /> O Q Inactive Q,Truck <br /> Longitude — I T Q Planned Q OTR Q End-Use Q Container <br /> 1 <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 /> QService Station QHauler QAgriculture QShredder �Other 1 <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 / FU / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q i 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 1 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 •` q' i II <br /> It <br /> Inspection Form Included: Q <br /> Comments Included: 0: <br /> - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® incorrect: X � X c A Mi r=' I� IGr <br /> ■ White Copy:CIWMB Yellow Copy:Operator _ Pink Copy:LEA ® ■ <br />