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Inspection Report Number <br /> . Waste Tire Su y & Inspection Repori� - p _ p _ -_ <br /> State of California A <br /> CIWMB 181(New 04/04) Survey Form - Page 1 i J 10 1 3 4 4 0 <br /> California Integrated Waste Management Board - - <br /> PartA- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID. Inspection Type (Fill one) <br /> Site Suffix: J l 1 I `� ' Routine Q Re-inspection Q Referral Q Observation <br /> j LocalI` If Referral,choose referral type(Fill one) <br /> Identifier:i 1 (} r '� � (�� - C,�,ll�7 � (1�..�(r L� � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Namej <br /> Inspected By Inspector <br /> Physical Address Jr Dir_�' — I 1 I <br /> Street <br /> Inspection Date <br /> Cit -- ---r' Time In Time Out <br /> City State ZIP Code _.._. _ <br /> Business Rep Title /jO AM O AM <br /> I <br /> 1_q. O PM L' ' O PM <br /> L2� LU <br /> Operational Status Tire Type',,"5 ) A Business Role Storage Type <br /> (Fill one only) (Fill all that (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTEj <br /> ! 1 Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude D #Closed Q Altered l <br /> GPS Q Hauler Q indoor <br /> Q Inactive Q Truck <br /> _TT1 Longitude Planned Q OTR End Use Q ContainerQ <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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A '.HAULING AND MANIFEST REQUIREMENTS 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 /> 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 I 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 Q Other: §. <br /> Comments S,1 l ! ( t :7 't J l: tI i <br /> �.(;Ltltlll ..>( k VI ldii-= lr'i`.'�. 111 .,/ T�i�' �'.. t ilf Y ( rC <br /> 0 (61.1"( '!F , 1( • ��1(' ��'b"r(i �_- � � ( fir; <br /> t(.� C �< I%�:' �;( t :_,14-L(" `�� �� j t t> C� - �'��_, �✓".c,( � �i=�if,' ,• { I(_✓� '"��f' ('1 .; �[�`f' '. i''' I <br /> r , 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 1 C 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />