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YY�!te Tire S & Inspection Repo Inspection Report Number <br /> ■ "as"m39 ifornia Y a ■ <br /> �YiS9 CIWMB 181(New 04/04) <br /> SurveyForm - Pagel - 13 $ Q <br /> California Integrated Waste Management Board ---- ----------------- -- <br /> Part A- Survey __ BLUE OR BLACK INK PEN <br /> Business Profile't,: y. <br /> I� TPID- j�f. - Inspection Type (Fill one) <br /> Site Suffix ! I Q 6 �� f ® Routine Q Re inspection Q Referral Q Observation <br /> - - - - - — <br /> Local �.. If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street j Inspection Date f <br /> State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM m 0 AM <br /> (4 PM 1 I I ' O PM <br /> ®ilaI Status " iltss Role `(`orage pe <br /> (Fl e only) (Fl all that apply) ( I°alll that apply), <br /> Active <br /> Q Generator Q Outdoor <br /> Q Closed Q AId t+ <br /> GPS Latitude II_JII �� ;r;� �� Q Hauler Q Indoor <br /> C Q Inactive Q Tri,+ �'f r <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that <br /> Q New Tire Dealer Q Auto Repair Q 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 /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q 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 <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FP / M / FT]Q Q 14 CCR§18459.1 (a)(b)(c) Tire Program ID Number from CIWMB <br /> Q 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/CIWMB Enforcement <br /> Q 0 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 ; /! ^_T7 <br /> (; �'`1G I' �..j _ f 1 /Gy- i'7 / r. - <br /> �l'-�rLLI �-.,c' �• f .e T7f 'f't� �v��r,: {- t... i_�_ �: e.. <br /> /1,�. :i r" c:�•�1 :,. i � :. : f -,r y t .� r.' >_ _ j,.. ..:- �. .�- _; ,<�t r�`r ._�.i <br /> r <br /> Inspection Form Included: Q <br /> Comments Included: Q -_ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ® _. P 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X /p \/ �� �I d =` ! L-1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> i <br />