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Waste Tire Su0ey & Inspection Repor Inspection Report Number <br /> _ --- <br /> ]3 Y` State of California <br /> CIWMB 181(New <br /> Manage) Survey Form - Page 1 5 . 1 0 1 0 5 3 0 <br /> California Integrated Waste Management Board ? <br /> Part A Survey E BL <br /> r r M� m � F � � BLU OR ACK INK PEN <br /> ^ <br /> TPID- 0 <br /> x: Inspection Type (Fill one) <br /> Site SuffiL -) 0 Routine 0 Re-inspection 0 Referral0 Observation <br /> Local +F If Referral,choose referral type(Fill one) <br /> Identifier: r tY >,.1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> , r <br /> Physical Address <br /> �. r, ... <br /> Street tC m <br /> r - Inspection Date <br /> t m <br /> City State ZIP Code Time In Time_O1111t _ _ <br /> Business Rep Title F-7 Q AM Q AM <br /> ' QPM l QPM <br /> + O erational Status Tire Type i Business Role Stora dT e ryry <br /> ( , <br /> p yp g yp <br /> p ® g (Fill all that apply) (Fill all that apply)1 <br /> Tire Count Whole/PTE i <br /> (Fill one only) (Fill all that apply) � Generator D Outdoor <br /> II <br /> ( > Active Passenger <br /> 0 0 Closed 0 Altered <br /> GPS Latitude j, . 1 _ —{�j Hauler Indoor <br /> j _ 1 D 0 Inactive 0 Truck <br /> Longitude - Planned 0 OTR End-Use Container <br /> Business Type (Fill all that apply] ' <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 m EJ 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/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 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments (�?. + <br /> t ' <br /> / ( a <br /> l L,i `>✓ ,j ' L - V/ iJJ�L:t t �e�it )r r V C c, k ` (�f <br /> t. f j j s <br /> /.J('} Ifl(!/o 110) <br /> Inspection Form Included: 0 <br /> Comments Included: 0 _ - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> L, <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X "� \/ i:- ;<; A ,Mi P I_i I". i c 62081 <br /> White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA <br />