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Waste Tire Surve) & Inspection Reportspection Report Number <br /> -0 <br /> Wig <br /> State of California A ■ <br /> CIWMB 181(New Survey Form - Page 1L_16 Q 1356 � <br /> California Integrated Waste Management Board - � _.-_.____ ._..._ .i <br /> Part A Survey BLUE OR BLACK INK PEN <br /> A Inspection Details <br /> TPI <br /> - : l (\fI Inspection Type <br /> (Fill <br /> oSite Suffix 'f oute 0Renspection Q Referral Q Observation <br /> Local ` ' {{ If Referral,choose referral type(Fill one) <br /> Identifier: ?,t-` d_t ;:{;� \_ r i 0 CHP 0 CIWMB ® Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J Inspected By Inspector <br /> Physical AddressF/ Fo �— <br /> ._ 1 <br /> IK <br /> Street � � _ <br /> Inspection Date <br /> city State ZIP Code Time IIn _ Time Out <br /> Business Rep Title 0 AM 0 AM <br /> O PM O PM <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 /> V l✓(yy <br /> 0 Active D Passenger 0 Generator 0 Outdoor <br /> O <br /> PSLatitude Closed Altered <br /> G <br /> l Q Hauler 0 Indoor <br /> Inactive 0 Truck <br /> O O <br /> g 0 Planned (� <br /> Longitude _ 0 OTR 0 End-Use 0 Container <br /> taus'nes'7 Type (FiEl ail that apoly} <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 4 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 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 <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 I 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments + <br /> �:X; tr�iii r� �� _ lrotii -r_ Lkll p( frr ; . ✓1 t� y <br /> at L)f'1 i� 1�< rt Y .( ty1{'.I ('r'i 17;•t l Y'j +� Y 4(';,( [ I L/ ._ r t L. <br /> lad 1 ►�� . I?k,)w,j;�ttii Lyd -1rc.of-,- 1.,, �.';I '; ft r( � jor {t:� <br /> r .I <br /> `. r. T. ,! J,., <br /> Inspection Form Included: 0 <br /> Comments Included`. 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X A, ,10.1, p_�I <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />