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us ection Report Number <br /> Waste Tire Su :,& Inspection Reporp /' /� <br /> ka <br /> State of California 1 Lit 13 V CIWM6181(New04/l14) Survey Form Page <br /> California Integrated Waste Management Board <br /> Part A- <br /> WE <br /> BLUE OR BLACK INK PEN <br /> v ?.+:*c d ,::.sv'rr ,� w . : ,w r : ur(" _ �"` .;✓'�'°' a�P ��F��b��" ��rd "�� � . r . � n3au`r�i �:.y�'S�rJ � 't. y � �,��;> .a� :+.i_.,.�,�. g�,.. .-...2..w � xuM'"t _-,.�._.*;;L_.,.r.3. .�_f�:..��.� :.....�.�... 5 x�nom,,,„,, <br /> �+ Inspection Type (Fill one) <br /> PID- F T <br /> Site Suffix: `_ i �` 0'Routine Q Re-inspection Q Referral QObservation <br /> \ I-Local <br /> 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 /> - <br /> Street �Y Inspection Date 4 r� •^7 _� !!` <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM <br /> EE-] !—1—_J 0 PM � ' 0 PM <br /> 0 AM <br /> I ' <br /> Operational StatuBusiness Role <br /> �. <br /> T <br /> (Fill one only) (Fill all that apply) y )1) Ittttiltly�: �`? <br /> trGenerator �l�1ultifr r,it <br /> Active <br /> D Q Closed <br /> GpS Latitude Q Hauler ��� + "� <br /> Q Inactive <br /> Qr <br /> Longitude - Q Planned Q End Use � tts <br /> ,;r"^�. - ...Fg4 µ : a�j ddb+b�' `"�4�' �+Fr 'a �'{'���+ ����x"` 1 n, t H=: ✓�Yt s r ,�, y.a, ;"�''a a � r `��-"����� 1�^4�i�i,w <br /> 2w�.�„ •?..�'�,.., ';: +ay4 .r.�w,uy.>Lt`F��...x . �.,r.�.� ,h:� .,. _ _ ..r�s..1..J...� ."�W ,u+a.�.s....�._ u.; _�.� _.. � i <br /> d New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PR - (0 Notice Of Violation Q Extension <br /> C§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 <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities r <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> No"Violations <br /> Q Q Other: § - <br /> Comments - ST-L <br /> r f 1 <br /> r <br /> � = Y <br /> .., r "rff�,���` �""q"+ �"� "+�"��.1' 11ReSS Rep`S'$➢gnatur� ,j'.,F"."`��+.�$�. ryq,!c!t ..,�."; �..d`°" <br /> �3- �:= '- ter. „t,,,_..-,.._x...c�.�t..,-.�.-- - — _•' ,. <br /> INSTRUCTIONS ON BACK Correct:, Incorrect: ll r + h 1 ' .31 62081 <br /> ■ <br /> White- - © ■ <br /> Copy:CIWMB Yellow Copy::Operator Pink Copy:LEA <br /> i <br />