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■ �8r <br /> Waste Tire SuGay & Inspection Reporo AS-a tion Report Number <br /> ; . - - <br /> State,ofCalifornia <br /> California <br /> CIWMB 181(New Manage) Survey Form - Page 1 _� 9 - 1 0 1 3 0 6 <br /> onia Integrated Waste Management Board -_....__ <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> - -- — F111111111w, <br /> TPID- - � Inspection Type (Fill one) <br /> Site Suffix: f >t ® Routine 0 Re-inspection, 0 Referral 0 Observation <br /> Local j i 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 t.` Inspected By Inspector <br /> Physical Address --�— El� <br /> Street f u <br /> Inspection Date <br /> a _arJC. far, �, ) U � r <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title Q AM ' Q AM <br /> - Fj] <br /> s O PM : F7 ' OPM <br /> -- - Operational Status Tire Type i Business Role Storage Type„ <br /> y, (Fill one only) (Fill all that appCy)' (Fill all that apply) (Fill all that apply <br /> V 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> [:p <br /> --� J___�o ' ® Closed D Altered <br /> GPS LatitudeL I <br /> 0 Hauler Q Indoor <br /> T J 0 Inactive 0 Truck <br /> Lon Rude - �p r 7 10 0 End Use 0 Container <br /> g 0 Planned D OTR <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 /> V I A HAULING AND MANIFEST REQUIREMENTS <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 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 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 <br /> 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 I 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 1 Other: § <br /> Comments - 66 <br /> - _:_► S C t�t i . `x,1.5( „r �.G� ( rJ U Pix f -- - <br /> I <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> - - / 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X e A, 1b1. I <br /> ■ _ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />