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Waste Tire SL_ y & Inspection Report Inspection Report Number <br /> ■ <br /> 64-_-00 <br /> State of California D <br /> __.. _-.... _._...__...' <br /> CIWM0 181(New 04/04) Survey Form - Page 13 0 1 3 5 8 9 <br /> California Integrated Waste Management Board g _..�___ _.._. ...._._ ______ .__-_._ <br /> Part A- Surve xs BLUE OR BLACK INK PEN <br /> F - r�, kms✓wwt `�'.'' f (y( �" ✓�t"ice r G ��' �, r -. ; <br /> TPID- �� j Inspection Type (Fill one) <br /> Site Suffix: ! (a Routine Q Re-inspection Q Referral Q Observation <br /> Local -� If Referral,choose referral type(Fill one) <br /> Identifier: {Ut 7r{i fj((vi .,(I.( V.t- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Mame - - - - - <br /> ( Inspected By Inspector <br /> ( <br /> Physical Address C.__vt <br /> Street <br /> Inspection Date [Mi <br /> Eu <br /> W' <br /> L I __ <br /> City State ZIP Code Time In 0 AM Time Out OAM <br /> Business Rep Title. -I O PM O PM <br /> I ICS <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that app <br /> Tire Count (Whole/PTE) (Fill all that apply) (Fill all that apply) <br /> _ <br /> 01PActive Q Passeng " (4) Generator Q Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler Q indoor <br /> _7D Q Inactive Q Truck ; <br /> Longitude - 1 Q Planned Q OTR Q End Use Q Container <br /> �. '77""­:^­J <br /> Business Type (Fit 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 (3, Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <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 /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m m m <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 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 O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> :t 4. i slti 'F I' l-,i i' r( f lJt. '/ <br /> j ( ((r _ J 1-4c". <br /> / <br /> 1,'✓tj {� �tf/ h+'.(`-` � I( P_,i(`d�{ �'✓it 1t-i.. t :. >~ rk !`4i; <br /> 66 � � ! <br /> -�. <br /> U`i1L/ o <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: I I l IFFl t 3 62081 <br /> e . <br /> e. <br /> 1 t _ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />