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® Inspection Report Number <br /> Waste Tire SL*ey & Inspection Repor._ ■ <br /> State of California -1 _ <br /> CIWM6181(New 04/04) Survey Form - Page 1 , 0 1 3 5 9 <br /> California Integrated Waste Management Board -- - - - - - - ---- <br /> Part A Survey BLUE OR BLACK IN PEN <br /> d jnspection Details <br /> Inspection Type(Fill one) <br /> Ste Suffix: �/ F�)EO T ?; J 1Routine Q Re-inspection O Referral Q Observation <br /> Local /' If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP OCIWMB OCom taint OEducational Visit OOther <br /> Business or Facility Name /='� t r Inspected By Inspector <br /> �v 0 V <br /> Physical Address <br /> Street Inspection Date <br /> City ; State ZIP Code Time In Time Out <br /> Business Rep l.; Title O AM O AM <br /> 0PM 1 1—� � 0PM <br /> Operational Status t r ped" Business Role <br /> (Fill one only) l' �I�f , l (Fill all that apply) ) <br /> ® Active @ Generator ti a <br /> m C 0Closed <br /> Latitude W , (0 Hauler <br /> Inactive � t�t�k"� <br /> r t fg;k <br /> O End Use <br /> Longitude — Planned <br /> _ p <br /> Business Type ( iii stP a app Y <br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer Collection Q Crumb Rubber <br /> O Service Station ® Hauler O Agriculture Q Shredder Q Other — <br /> — _J <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A ` HAULING AND MANIFEST REQUIREMENTS <br /> V I(D Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements i Date ip' m <br /> Q 0 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 /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 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 0 In Compliance - No Violations <br /> Other: § - - <br /> Comments {{ <br /> t <br /> l i✓lir O <br /> �I.�f��r ( F✓� 1:.)( ( �tCr ( <br /> 1 w(� I( i i i/f' T/lj l ti }l i%tCf>«1 r L/I r' i �!f t'� �t l'bi F' add <br /> ✓� = �r� <br /> X ,,YCt.l(`✓ � _i `; Q� Y7Fi',•f; l�(�_ t✓ . ` :'rE_ U �C" r <br /> #4 a{=w x ��*"� ' �{ "� ,�",a 'I"3 e rel ,�,k,r ' ,�„ ,y y,Yr���;� a ;� I t ;�l p'�'Irl✓+ <br /> R m+wra�%� tj»•h ,�V r:�f f r PrP ` �, > t�, "/ „ <br /> l� , .4;,* <br /> . �, .� � �,,,, � . <br /> t I ° .r smess Re s S' r nat re P r 1SI µ. CI) - " t ,`�ale <br /> rzd t►1 ", ' 2(" <br /> 3 p I c <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: l 62081 <br /> �/ � <br /> ■ Copy: <br /> -- Copy: <br /> p Copy: ® ■ <br /> White Co CIWMB Yellow Co Operator Pink Co LEA it <br />