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■ Waste Tire Sup ey & Inspection Repo,* Inspection Report Number <br /> - ■ <br /> State of CaliforniadW.-ii.211 SurveyForm - Page1 1 6 . 10250^ 45 J <br /> 9 CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board - <br /> �Part A Surve BLUE OR BLACK INK PEN <br /> ' TPID- `� r r Inspection Type (Fill one) <br /> Site Suffix: f 1 �' ( �� /`] ® Routine Q Re inspection Q Referral Q Observation <br /> Local n _ � If Referral,choose referral type(Fill one) <br /> Identifier: Z'1 � ,t - k �L•to V 'lx t f,. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> ' p y Inspector <br /> L� <br /> Physical Addre s L <br /> 0 `{r , t <br /> Street <br /> _ <br /> I y Inspection Datev .. LL2L�,� <br /> � EbEb <br /> / <br /> I <br /> City Mate ZIP Cade <br /> Time In Time Out _ <br /> s Rep Title j - O AM O AM <br /> usmes <br /> 0 P OPM <br /> k 2 t �._.__,__ _.. _, _ . ._. <br /> i�r <br /> Operational StatusTire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply)� (Fill all that apply) <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> p Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> ..Suslnes r r r r aa a fbi •� " u .+ .., a''""r)ta)!'^•w a cl u5' ,y. 0^T.r1M <br /> y <br /> X.f,w .aw—.,t.. _,._.aw.�._ u� , ,:X ;,s .�..4�u�2:�G aiX._ :t, ,o .t , 'F. .... 4. Pi�yu� ,�."'V.�"a.;�, '�v '�,ttXi�'^ '�a w,�:�° ."',�r ^t^I�cK`'"r,:°• : `w<"" ,+`:' 'w'ryy ,?r' %"�"�. �wi <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 (P 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> / <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 m6- 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 t 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 ': l <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> -- 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X � a/ +. �, !. i <br /> ■ �J <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />