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® Waste Tire Sl• y & Inspection Report InspectionReport Number <br /> - - - - --- <br /> ?-^. State of CaliforniaCIWMB 181 04/04) <br /> f/''�i �� , <br /> California Integrated Was eeManagement Board Survey Form - Page 1 10 2 5 )7 i 7 ! <br /> Part A- Sull BLUE OR BLACK INK PEN <br /> I R�.I1t1@$4S P17 <br /> r�?Yr <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: J� 0, <br /> Routine Q Re inspection Q Referral Q Observation <br /> Local — If Referral,choose referral type(Fill one) <br /> Identifier:_ _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> 4 Inspected By Inspector <br /> Physical Address ----JE__i F11 ) Ell a",`-- <br /> Street <br /> Inspection Date I r <br /> Cit} State ZIP Code <br /> I Time In Time Out <br /> -- - <br /> Business Rep Title ` <br /> ) , r 0 AM _p O AM <br /> 0 PM __1____.+ O PM <br /> v n <br /> Operational Status Tire Type Business Role Storage Ty <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 /> O Q Closed Q Altered <br /> PS Latitude <br /> G <br /> . Q Inactive 0 Truck Q Hauler Q Indoor <br /> Longitude - -� ��— 10 <br /> Q Planned Q OTR Q End-Use Q Container <br /> 6t+slness 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 /> 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 <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-Re jistration/Decal in Vehicle <br /> QQ 14 CCR§18459 -'Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <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 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q In Compliance - No Violations <br /> Q Q Other: § -- <br /> Comments <br /> - - -- <br /> Inspection Form Included: Q <br /> Comments included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: 62081 Incorrect: ;a �,r, jw I <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />