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Waste Tire y & Inspection RepdO m <br /> Inspection-Report Nuber <br /> ■ 4 OLS, State of California I -...._ <br /> CIWMB 181(New 04/04) Survey Form - Page 1 -- $ BLUE 1 3 4 ZK I�9_ <br /> California Integrated Waste Management Board <br /> Part A- Survey PEN <br /> r�r. 9„1dk„ <br /> TPID- - - f Inspection Type (Fill one) ----- �y_-- <br /> Site Suffix: I f J CRoutine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Jl ; /. - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address I (! [Id2l •J�h�Yl.t L{ r <br /> Street ` <br /> Inspection Date <br /> .� �/ 'moi` Time In e Ou <br /> State ZIP Code ___ _ �� <br /> CTime t <br /> city � _ <br /> Business Rep Title t >� : ( 0 AM <br /> O PM �� , g O PM <br /> � ' �1 j Gtr) - 1 r. <br /> ��. L -1 <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 /> ” ®Active Q Passenger Generator Q Outdoor <br /> PS Latitude O Q Closed Q Altered <br /> F1 <br /> Q Hauler Q IndoorGO Q Inactive Q Truck <br /> Longitude FTT- -FF1�`1 oPlanned aOTR Q End-Use Q Container <br /> t#",6,1" Pe (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 Q Other �4t�l I TI,-at <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS - <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> - - - . <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 /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 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 /> 0 0 Other: § / - - <br /> Comments > �i r 1 1 i; /' l i n <t✓ i l <br /> YIt ' ( l� %i. t , �.�,f <br /> CttblP! J:oc r � �7�� <br /> ore (t �(' -C/ t('{t:( �JU fG �'l�d_ it �l►1(y4i re, 1,1 <br /> I 0"t WIN J bit , It �ovt Lc_Vcd r1 FYI �-�f P <br /> -,r <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X <br /> ■ White Copy'CIWMB Yellow Copy:Operator Pink PY LEAp_. W <br />