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Waste Tire Suf► & Inspection Reporspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 _, g I 7 <br /> California Integrated Waste Management Board <br /> Part A- BLUE OR BLACKN <br /> �.[,�SIk1eS,S`.�F'�f``Ile'� ea r?�' "5 � i r 4 y N "' m �1'iM"��.'pLCt►on Details ya;;r �� <br /> - <br /> TPID Inspection Type (Fill one) <br /> i `" - J <br /> Site Suffix. Q Routine Q Re-inspection Q Referral Q Observation <br /> Local --� - - `- 1 - -- - If Referral,choose referral type(Fill one) <br /> Identifier: 641 1 +.;, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility NameI <br /> jii Inspected By Inspector <br /> Physical .Address <br /> Street_,,. <br /> ) <br /> "�• 0 -7 Inspection Date llL/2-L] <br /> c1 , - State ZIP Code I Time In Time Out <br /> Business Rep Title _ + AM O AM <br /> I 1a . �_. � PM EE : E_0 0 PM <br /> tAe � __ <br /> Operational Status e;�ype , Business Role Sgey e <br /> (Fill one only) (Fill til#hat apply) (Fill all that apply) (Fill all#ha#apply)., <br /> IreCourt 0� <br /> ai ^. �, n Q Active Q Fa5sener Q Generator Q Outdoor <br /> D Q Closed Q Altered ' <br /> GPS Latitude <br /> i Q Hauler Q Indoor <br /> E] L I I I <br /> ® Inactive Q Truck <br /> Lon Rude - Q End-Use Q Con#a '(ner <br /> _ g !!! Q Planned i:?fiR <br /> Business Type (F'tllWl"tE7sf <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> I <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 /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 FF / m / M <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q i Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <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 Q In Compliance - No Violations <br /> Q Q Other: § - <br /> Comments <br /> ! { % Vi('( 1� '�(t � l >rl <br /> (,�i t�, r� -Si(I ; l `' � ;� -- � r1`ts ar J ao ,(7556 r FIc ' Vcl( cl_s(J <br /> y.,)ie� �! ' <� t' RY 'V! �? r'1 t i.f ..�-o l(i <br /> v <br /> r g .„h r <br /> Business Rep"s Signature Phane Number _ Inspector s S nature r p <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect - ,� f�'d4 Y►.� q ' <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> I <br />