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R-12H <br /> Intion Report NumberWaste Tire Survey Inspection Report /� l� `r Stateof BCalifornia Survey Form - Pagel C�_ �f - 1 0 L Rf i <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board — ---- - -- -- <br /> Part A Survey BLUE OR BLACK INK PEN <br /> "M!" X r �.•.t rysir""„+r '�,� ta;.' ,n W<"b'.w^i de^"dn pi+rr <br /> a` TWO <br /> TPID- ` Inspection Type (Fill one) <br /> @ Routine 0 Re-inspection Referral <br /> eferral 0 <br /> O�rbs s;re,r'vt ai{�t`ionSite Suffix: <br /> I <br /> F 51 fl . <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: (,�h 0rt 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ��� U LTe v t.(/y l <br /> I � 1.3�} 5 1� 1gckV�,�b✓e �� � <br /> Street /, <br /> Inspection Date V 2 �j / L <br /> 31 <br /> a U 1z] CA I ✓ �c <br /> City _a State ZIP bode Time In Time O_ut T.-I <br /> Business Rep Title O AM O AM <br /> T, PM <br /> Operational Status T Lr Business Role storage Type <br /> JD (Fill one only) (FI � h ' I (Fill all that apply) (Fill all that apply). <br /> ImL <br /> r, m 6 <br /> 0 Active ( f ( 0 Generator 0 Outdoor <br /> t 4 1 <br /> D # Closed <br /> GPS <br /> Latitude 1 W gar" <br /> �a«xrt��, 0 Hauler 0Indoor0 Inactive <br /> 0jta�iai <br /> Longitude – ” Planned QTR 0 End-Use 0 Container <br /> Type (F ill all than apply) <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 R► <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Q Other I !y'V� �)V)1�(i/ ,117 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 1 VA HAULING AND MANIFEST REQUIREMENTS <br /> ---------– <br /> 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 0 m / m <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/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> - <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 \I C , <br /> Inspection Form included: 0 <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: � i __.�! <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />