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■ �:�' <br /> Waste Tire S e inspection Re Inspection Report Number <br /> State B California ) <br /> Y p p - __ _ . -__, ■ <br /> CIWMB 181 New 04/04 �y j <br /> California Integrated Waste Management Board JU e 1 p <br /> � <br /> Survey Form _ Pa <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> J1 O { �t " f tW �r°nIyiq/r,rlsa w rl <br /> ' f.���..- <br /> TPID- Inspection T <br /> Site Suffix: L I F1 EI] <br /> p Type (Fill one) <br /> - - <br /> Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: <br /> ------ _. ' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - - - - <br /> Inspected By Inspector <br /> Physical Address <br /> Street � —"'� <br /> i- Inspection DateEE <br /> I <br /> Clty State ZIP Code Time In Time Out <br /> Business Rep Title _ O AM O AM <br /> PM f <br /> �l ii v s•.✓ <br /> II_ <br /> Operational Status; r( Business Role Storage Type <br /> TireOunt(Who�efPTE) (Fill one only) " (Fill all that apply) (Fill all that apply) <br /> � ti as , <br /> 0 Active 0 Generator 0 Outcloor <br /> O <br /> �+ 0 Closed <br /> Y°l�Jaa "�'t�i �i1 Y✓ ��wn��ona <br /> p yo ri„I If,dq )� 0 Hauler 0 Indoor <br /> O Olnactive ��/)�a � <br /> Lon <br /> 2 » 4l <br /> gltude 0 Planned ,�(" �Uk <br /> 0End Use O Container <br /> MV, <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 _ 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 1 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 1 O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / 11:1 m <br /> O O 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 0 Other: § 0 In Compliance - No Violations <br /> Comments <br /> t <br /> I <br /> nspection Form Included: O' <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X A 1.0, 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />