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Inspection Report Number <br /> Waste Tire �rvey & Inspection Re-p ` - pp � <br /> State of California "'J <br /> �$ CIWMB181(New 04104) SU�eV Form ' Page 1 /'�y 2 t 0 <br /> California Integrated Waste Management Board J J --- -- 2 --- ----- - <br /> Part A- Survev BLUE OR BLACK INK PEN <br /> petails <br />} <br /> TPID- Inspection Type (Fill one)Site Suffix. 0 Routine 0 Re-inspection 0 Referral 0 Observation <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 <br /> _ Inspected By Inspector <br /> Physical Address <br /> EET�__17 <br /> L Ji <br /> Street <br /> Inspection Date `] Z- <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> �� ' ----� ._ O PM 0 PM <br /> ° _u° Operational Status Tire Type Business Role Stora N a <br /> (Fill one only) (Fill all that apply)] (Fill all that apply) (Fill all"14 <br /> - I i" rur+ ur <br /> 9 p kyul T) <br /> Q Active 0 Passenger 0 Generator 0 O �rre <br /> D 0 Closed 0 Altered <br /> GPS Latitude , 0 Hauler 0 intl <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business 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 /> 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 0 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 — ----- 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 /> 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 /> 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 I 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 /> �, ,7 - t-•!✓ - -- _�J/iii. <�a�.. / ->r �/'gym/a,. --- �.t71 /'!'.i <br /> Inspection Form Included: 0, <br /> Comments Included: 0 Business Rep's Signature Phone Number Inspector's Signature Phone Number, a <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect A, `"�� <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEAS <br />