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Waste Tire Sup & Inspection Re ort Inspection Report Number <br /> � 3. tate Y p p - _ <br /> CIWM f 81(New <br /> Survey Form - Page 1 - $ i <br /> California CIWMB 181(New 04x04) <br /> 9 T$ <br /> Integrated Waste Management Board - <br /> Part A Survey BLUE OR BLACK INK PEN <br /> I Inspection Ct�ails <br /> TPID- t i �._. Inspection Type (Fill one) <br /> Site Suffix: - ' J a° I �� 1 ' - U� i ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local - } If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> t <br /> i ti _.. <br /> 1 <br /> Physical Address LLi <br /> l� ;rl t" <br /> Street ;rJ J r J Li <br /> l E <br /> Inspection Date <br /> 1 r - <br /> r <br /> city State ZIP Code Time In Time Out <br /> Business Rep Title OAM <br /> O <br /> AM <br /> HI : EE <br /> Jt <br /> j, 0 P QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply): (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger (a Generator 0 Outdoor <br /> Latitude . T-11 <br /> GPS ° 0 Closed 0 Altered <br /> 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck4 <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <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 (a Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> W 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 IE / IE <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 /> r <br /> �".( r. .l�.( i _ �iJi� _ i... <br /> � r <br /> (. -�r •___I_ �. 1 1. _ ,(' <br /> Inspection Form Included: 0 ' <br /> Comments Included: 0 , <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �a. ,�?„ <br /> 9. i 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />