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Waste Tire S! ns ection Report Number <br /> ka <br /> y & Inspection Repori�__p-_- --- ___p-State of California CIWMB 181(New 04/04) Survey Form - Page 1 1 00. __6_4___89 <br /> California Integrated Waste Management Board - - ---- - - -- ------ --- <br /> Part A- S <br /> yy tBLUE OR BLACK INK PEN <br /> TPID <br /> - l Inspection Type (Fill one) <br /> Site <br /> Site Suffix: J� � / � � r Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> a <br /> Street <br /> _ Inspection Date EEI <br /> LT-1-- � State ZIPCode Time In Time Out T_ <br /> Business Rep Title AM i AM <br /> 0 PM 0 PM <br /> i ���,<rtf <br /> Operational Status TtW� ¢ ���r���� Business Role Storage Type , <br /> 1% (Fill one only) (Fill all that apply) (Fill all that apply)i <br /> , rt <br /> r Q Active Q +"r�i Q Generator 0 Outdoor <br /> Apr y�l, <br /> C Q Closed Q Altere '' <br /> GPS Latitude EE Q Hauler Q Indoor <br /> Q Inactive QTrue'' <br /> Longitude — --7 -17 1 <br /> Q Planned Q OTR Q End Use Q Container <br /> BusinessType (Fill all that apply) <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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - -- - <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> 0 <br /> 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q 0 114 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 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 Q Referred/CIWMB Enforcement <br /> Q 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 Q In Compliance - No Violations <br /> 0 0 Other: § _._.__._-------- <br /> Comments f <br /> r% <br /> h ti <br /> Inspection 1tQr � _�'� �p�, ✓ m�� b , c ea � wa �ry <br /> `" <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Si" natur Phone Number <br /> '� I L Im�� ..` 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: •. iy. Xi A ��' � <br /> ■ WhiteCopy::CClW— ® ■ <br /> IWMB Yellow Copy:Operator Pink Copy:LEA <br />