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■ state ofcafiforn #y p pInspection Report Number <br /> Waste Tire Su & Ins Inspection Re or <br /> California <br /> Survey Form - Page 1 t 9 - 10 1 3 1 6 <br /> CIWMB 181(New 04/04) <br /> California Integrated <br /> i <br /> g ated Waste Management Board i <br /> Part A Survey BLUE OR BLACK INK PEN <br /> waw° "' T'r' w„✓„ an,%+;,r Jr ti d f „ ✓J„v v'-1 y;:;, a —r.,ac <br /> r w!r «S �fi�pb prnyitJn t.":c a^w r., >t:-,'„"r "� Nwnd:.r,/ �«+p"M � r. J, �'pb wr' n' � � sd. .t ;«1l ar ra'?• a "a „,.r„„. <br /> r E r, �✓, S f , „ >u, ,wY r kf .,y n ,aW?f a 6 ,'.”±':fa F�t., '”+' r „; p,"r„ ,f � �, �5 ,� i 1J :,,✓n ,r+ n ,.t <br /> 9 # r <br /> 'N.3,nM��'S"ti'<ci, <br /> TPID- i r. .� � Inspection Type (Fill one) <br /> Site Suffix: �i r I1 I V { <br /> 0 Routine Re-inspection <br /> Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Ta 41 JG a q, I r t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> t <br /> Inspected B <br /> Y Inspector <br /> l-.( ( <br /> Physical Address <br /> Street <br /> Inspection Date <br /> City Stag ZIP Code , Time In Time Out <br /> Business Rep Title AM <br /> J�ttl ' { /)/� 1 J.;i y (q' c:; �/ ��L—J' L_._a__::' PM r ! : F ] <br /> t } 0 PM <br /> 1 V If L r j <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 /> 461 Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude EE -tom__ LLI0 Hauler Q Indoor <br /> � 10 <br /> Q Inactive Q Truck <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> � r r <br /> Business Type (Fill all that fippiy) <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 <br /> Part B - Inspection <br /> of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A T HAULING AND MANIFEST REQUIREMENTS <br /> Q Q <br /> Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> -- <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance Deadline ` <br /> 00 <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date IE / ELI / [I] <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 /> 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 I Q Other: § <br /> Comments / 1 / <br /> II:+ Iri a r rl J' J I / r(}� �1 `i T: ' l ��t �'( �• f� � Gf <br /> fr4ct � rAJ f <br /> r t{��/JI'�F r <br /> Inspection Form Included: Q ` <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X d ^ L _. 62081 <br /> I:� :. <br /> ■ ® ■ <br /> White Copy:CIWMa Yellow Copy:Operator Pink Copy:LEA <br />