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Waste Tire S*ey & Inspection Repo _ <br /> i.G33Inspection Report Number <br /> $•. State of California� IWM181( eSurvey Form - Page 1 t- 3 - 1006428 <br /> CalfomalntWaste Management <br /> i <br /> -,._. <br /> Part A <br /> Se_ <br /> F ++ S.. p,K t ✓.;,�r <br /> �u . 'yRv+:,aB,LUE.> OR BLACK'IN�. Ku'am Pr,Et..r, <br /> wN <br /> rituln •aRr '-n'N` ; 7a ' y� � � r'pn DealAn•, w } <br /> Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: d- <br /> ,'.,.,t <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical AddressL __j FT <br /> :.l ' ^� <br /> Street <br /> Date <br /> Inspection m� <br /> p <br /> city State ZIP Code Time In/ . _ O AM Time Out O AM <br /> Business Rep Title �.. O PM — C— Q PM <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 /> The Count�Whc�l�'PTF"� (_., <br /> s 0 Active 0 Passenger Q Generator 0 Outdoor <br /> - O 0 Closed 0 Altered <br /> GPS Latitude _ 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> r <br /> Lon itude — End-Use 0 Container <br /> 9 Planned OTR 0 <br /> O O <br /> ,,.,. <br /> ?.fuss ness Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> i <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> V __ <br /> --- 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers, Compliance Deadline <br /> 0 ''I 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> m m m <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 /> 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 _ <br /> _ �!� aAC' '/l:_ ,-li r.�/V�1w: \/' 1.�' "AIX, <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: X E Incorrect: ;:� a �T-FT 62081 <br /> i ="y <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />