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Waste Tire Su$ey & Inspection Repor -_ p port Number <br /> : Inspection Re ■ <br /> e;; State CIWMf81(New Survey Form - Page 1 ( 0 -1 3 5 5 3 <br /> _ - <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Surve _ BLUE OR BLACK INK PEN <br /> flSpeCtiOn Det�l a'" y 'tPlr <br /> TSite SuffixPID- Inspection Type (Fill one) <br /> : (•- <br /> �1 Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> C�QaI , If Referral,choose referral type(Fill one) <br /> Identifier:., 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name i ! <br /> ( Inspected By Inspector <br /> ot <br /> Cal AddressEI <br /> Physi _3 _ ®) f L1 <br /> Street -- u <br /> t, Inspection Date <f. 1 J / } /� <br /> City State ZIP Code ( Time In _ Time Out <br /> Business Rep Title 0 AM 110 AM <br /> PM 0 PM <br /> f t/1 CA Gi, <br /> Operational Status Business Role <br /> �wk r <br /> (Fill one only) ( 1! ()tr�' (Fill all that apply) ) t �) <br /> ,+'';l <br /> Active dq!�t e , rn;r. ® Generator <br /> [-- L LLL <br /> D Closed <br /> ��++ Latitude Hauler <br /> r n r t Ln� <br /> GPJr nfl <br /> 0 Inactive <br /> Longitude 0 Planned 0 Ed Ut t 11 <br /> t) <br /> f� F Mr w u i. � u r rte; � �,w�^1�✓^tzh`l�"r`� "e{ <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> i <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other r�ln s �v i i- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 . PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 NoticeOfViolation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 114 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 I 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ----- <br /> 0 1 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred f CIWMB Enforcement <br /> 0 0 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 r In Compliance - No Violations <br /> 0 I 0 Other: § _ - <br /> Comments <br /> [",.kwl� { C•j j1�lA d. ? 1 � � Or, �('Ir t l ti rF- <br /> f�( I 4, t iJ �1� v ��7 r'l_ � (F 4'.. �i� v ! Jl �Wt I <br /> i ! !�, �4t ( 1� f C.) <br /> 7,ni <br /> Inspection Form included: 0' <br /> Comments Included: 0' <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X Gf, �A, 1,0, E, j i I <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />