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Waste Tire Su y Inspection Report-Lnsction Report Number ■ <br /> . .. I <br /> State of California Survey Form - Page 1 ; 1 5 - 1 8 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board ........._.. ....- <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> �.. V�"Fy�� re a �� i d �'' �' &° .0y�` � ✓ ��am Hf,,,!r 4 '� r'7 ,inn�. <br />� - Inspection Type (Fill one) <br /> Site Suffix: `1 � � Q Routine QRe-inspection QReferral <br /> d ObservationTPID- <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: C) [t.-i ;u �, { Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> t-1. s I If U <br /> Street Inspection Date <br /> City StateZIP Cvde Time In Time Out <br /> Business Rep Title �O AM O AM <br /> j0PM � � � 0PM <br /> I� �ILt <br /> Operational Status Business Role <br /> (Fill one only) � 1�' (Fill all that apply) , u� ? <br /> Q Active s } �; Generator <br /> -,O <br /> Q Closed t � �mi �tP <br /> s r k k <br /> GPS Latitude t' Q Hauler <br /> - Inactive <br /> Longitude - Ll_11-11 <br /> Q Planned ala r i ' Q End-User �(%a <br /> r <br /> r ryarf`r�a'vrN�"x <br /> oa- <br /> Q 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 /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS p <br /> Part IHAULING AND MANIFEST REQUIREMENTS I r. <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <br /> Q Q 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 /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 14 CCR 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q <br /> § Y q 9 <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 <br /> Q to Compttance No 1/totattans <br /> Q QOther: § , <br /> Comments r r 1 - u t'U F; r' r I - <br /> - - 4/vtv1'`J `l fi { t [th 114%/ t'v _t� `fit{ tIVPvle VI I' /� �, C)Lcl 4f , <br /> �'Gk1r' �v C✓/nFY � -I !)( t/ E% 1 }tc:.t" lyrl Y L)C.4 ttKe S <br /> 1 �� �� �f c� •- . 7� ,c ;� �; flit q e r 3 C-r-, f e- fc n vV ct �t 42 tires Q �- a - <br /> r14lC.tVld UoclC9 ` tGh Ire <br /> P✓DCvGW) Vz uI✓-e If -S. D t)peded, <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct Incorrect: ( i Y �/ J .. 2 <br /> SWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />