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w. Waste Tire Su y*Inspection Report In tion ReportNumter <br /> : State of California p .._..._ <br /> ® TS.ta <br /> Cl <br /> WM6181(New04/04) Survey Form - Page 1G 256 ' _ <br /> California Integrated Waste Management Board <br /> BLUE-11 OR BLACK INK PEN <br /> Part A Surve <br /> TPID- Inspection Type (Fill one) <br />} Site Suffix: J ;- ® Routine Q Re-inspection Q Referral Q Observation <br /> Local Ff ` If Referral,choose referral type(Fill one) <br /> Identifier: 0 (A t 1 �1 rJ V.7 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> A. , <br /> ILIA,—IL, <br /> It( ltrl(.. t <br /> P I Address r <br /> Street <br /> Inspection Date <br /> L1 :,� r � I �� <br /> Crpy -- State ZIP Code Tlme In Time Out <br /> Business Rep Title O AM OAM <br /> MOO ___ LEI 0 P LLI __ 0 P <br /> Operational Status Business Role � a <br /> ;k m".� <br /> (Fill one only) LFII► I Y (Fill all that apply) (Plr �g <br /> Tire C'," qt(Whole1PTE) <br /> w, N <br /> Active Qal o ® Generator <br /> D Q Closed <br /> GPS Latitude —L I L__1_J la t;reit Q Hauler � <br /> Q Inactive <br /> Longitude - � Q Planned �i� Q End Use Q CaYttlher <br /> d <br /> Q New Tire Dealer Q Auto Repair (D 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 /> VA HAULING AND MANIFEST REQUIREMENTS <br /> - - Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 m <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date W m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q I 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 <br /> 2-0 <br /> r- r' <br /> Cli'i Irr C ?Cc -( L(1 —ol ??�' � W6 , t� ��if�� ��U� �� !�bf•:� �6..11.Je+r <br /> aw <br /> t �Y c�' j `f' _o c'P I?+,ter y ,t� f cc rv1.�t¢ `F <br /> Inspection Form Included: a! <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number. <br /> 62081 <br /> X <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: ^ Vn <br /> ■ C _.... <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />