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Inspection Report Number <br /> T Waste Tire SuAy & Inspection ReportLL�. <br /> p pa��us CIWMIState 181(orniaSurvey Form - Page 1 0 1 0 8 ,1_ 2 - <br /> 48i ffi CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A Surve I BLUE OR BLACK INK PEN <br /> Irk. �1171 <br /> ��a <br /> E <br /> Inspection Type (Fill one) <br /> Site Suffix: /� % 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Z r i ;_ - ,- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> i <br /> �Physical Address�`� ,..� � � 0 `� '� - ✓�� I . <br /> Street Inspection Date = / ' <br /> city State ZIP Code Time In Time Out <br /> Business Rep Title I : 0 AM0 AM <br /> O PM O PM <br /> Business Role Storage TypeOperationalStatus Tire Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that app <br /> ly), <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> 0 Closed Q Altered <br /> GPS L'titde II� Q Hauler Q Indoor <br /> Qnacve 0 Truck <br /> O Q End Use Q Container <br /> . [--- <br /> LongQ Planned Q OTR <br /> i <br /> Business Type (Fill all that apply); <br /> 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 " 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-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m M <br /> FTI <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> (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 I 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 /> O O Other: -- <br /> Comments <br /> Inspection Form Included: Q <br /> - <br /> Comments Included: QInspector's Signature Phone Num her <br /> Business Rep`s Signature Phone Number g <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X + '�° `- " <br /> _ _.: ® ■ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />