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-= Waste Tire Suo;y & Inspection Report- Inspection Report Number <br /> State of California <br /> CIWMB 181(NewSurvey Form - Page 1 I 1 1127562 <br /> California Integrated Waste Management Board _.... —. <br /> Part A Survey BLUE OR BLACK INK PEN <br /> DtsineS inspection Details <br /> Inspection Type (Fill one)TPID- <br /> 1313Suffix 5 � Routine ORe-inspection OReferral OObservation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier ( f �� O CHP Q CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> _ -1 �!itf a Physical Address . wck <br /> ............................. .... <br /> Inspection Date Iq <br /> ! <br /> bcf� 7 75 t...._..... <br /> st il, �„_ R,^rd Time In Time Out <br /> Business Rep Title / € O AMQ AM <br /> PM <br /> OL Im PM <br /> 7J ew. / t .fes' tat <br /> Operational Sus ire yee ti Business Role <br /> (Fill one only) 11F, 11 lh ,apply) (Fill all that apply) <br /> Tire'Count(Whole/PTE) <br /> ? O Active ", e5er• e� Q Generator <br /> GPS Latitude <br /> 1 ,O ® Closed a <br /> Hauler <br /> - - Oinactive <br /> O I <br /> �.;. <br /> Longitude j O Planned O End Use <br /> �1 e Ali itis �� NINE z �, x h <br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body 0 Car Dealer O Collection O Crumb Rubber <br /> Q Service Station O Hauler 0 Agriculture Q Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> i <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation O Extension <br /> O 0 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 Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive 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 /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> O OOther: § <br /> ---- <br /> Comments <br /> Al P-W <br /> (P,, t ,t i1,,M S `00 O:(' j( ,,,, t ,rj IA� llyu t4j ! -Y1 j <br /> -- - -- - - <br /> rrtspec#1©n ©rte lrludecl ? � <br /> Coriyrnent °trtd4lided <br /> O �_ <br /> Bali l ep.s..St #ure Phone Number Insp , & ,gn #urle Phone Number <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X �f a , I � 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator _ Pink Copy:LEA <br /> ii _ <br />