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Waste Tire Suay & Inspection Report Inspection Report Number ■ <br /> ii• umi`. State of California <br /> iYt7 ' CIWM6181(New 04/04) Survey Form - Pagel <br /> 1 1 0 1 0 7 21 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> :r"".� t + d7, h ``"7"7 �r, "a^y+�+ri' ,3` ' i""' ;��'�f <br /> ,r � 5j�1r(3t� FrpL} t ��l r <br /> TPID- Inspection Type (Fill one) <br /> /'1 <br /> Site Suffix: i 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 Other0f . 4i GJ <br /> Inspected <br /> Business or Facility Name <br /> Inspector <br /> Ue <br /> z <br /> y <br /> Physical Address J <br /> Street <br /> {{1 _ Inspection Date <br /> 011 /u <br /> ----- t Time In Time Out <br /> State ZIP Code <br /> Business Rep Title O AM O AM <br /> � PM <br /> I__ F] O PM <br /> Business Role <br /> Operational Status <br /> It'» (Fill one only) ( I (tl �� 1 (Fill all that apply) (F1 "I+ PpIY) <br /> Active <br /> �r „ Q Generator (door <br /> D Q Closed <br /> GPS Latitude Wq a f( Q Hauler )tt+xa41 s <br /> 0 Inactive <br /> Q Q Tack <br /> Longitude - Q Planned 00 Q End-Use Q Container <br /> Business Type (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 i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / FTI <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/CiIwMB 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 : In Compliance No Violations <br /> O Q § <br /> i Other: <br /> Comments �: (:i, {•�i �`/i _C 1 L 'r`'l f; (` ;� t L`1 { ,I <br /> 1 _j t k e ✓�t _ t �. <br /> f+`.'i.t .'t' iy°r r (�I a�t' ! t1 <br /> Inspection Form Included: Q' <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />