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Waste Tire Su & Inspection Reporspection Report Number <br /> - - <br /> State of California Survey Form Page 1 i - 100664V <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board __ -,. , <br /> Part A- Surve _Y BLUE OR BLACK INK PEN <br /> [1Sp@Y � r + � � V �4221 <br /> ak i J tr 4 anti°� rrr'4! <br /> _ K.,L , 7 b' 4 iH ��i <br /> .� .._._.... ua d w <br /> } <br /> TPI <br /> D- Inspection Type (Fill one) <br /> ' Site Suffix: �_ -.. - i <br /> Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 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 <br /> Inspected B <br /> p y Inspector <br /> ----- - .. -- _ <br /> —] L <br /> Physical Address - iLl <br /> - <br /> j':. , , <br /> Street m <br /> � Inspection Date - <br /> _ <br /> ti <br /> city State ZIP Code I Time In Time Out <br /> Business Rep Title �1 Q AM0 AM <br /> I�a� � 0 PM _I . Q PM <br /> Operational Status Business Role � r9Y6 <br /> (Fill one only) ° (Fill all that apply) <br /> @ Active . Q Generator <br /> GpS Latitude . 0 0 Closed O Hauler <br /> Inactive � t <br /> 0 u ��r�il�M <br /> Longitude - 0 Planned 0 End-Use <br /> Q New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 11:1 <br /> / m / m <br /> 0 0 14 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 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 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 <br /> 0 0 Other: § 0 In Compliance - No Violations <br /> Comments <br /> L <br /> f <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> � e <br /> INSTRUCTIONS ON BACK Correct:, Incorrect: X �. � A , ,,„ L 1 62081 <br /> I ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />