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-- <br /> Waste Tire Sdoey & Inspection Repor Inspection Report Number ■ <br /> State of CaliforniaMB 181 <br /> rtew 04/04) <br /> Californa Integrated Wase Management Board Survey Form — Page 1 j 1 L _ LY J <br /> 5 _. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> ,� ,r�,"�,r"s, Inspe..ction Details <br /> TPID- <br /> I-4E-1 <br /> LoEl Inspection Type (Fill one) <br /> Site Suffix: lJ Cj & Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �- / If Referral,choose referral type(Fill one) <br /> Identifier: ]y T O(�C [;6t/ ( ;rj fc".� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address _j <br /> Street r T <br /> t Inspection Date 0 <br /> City - State 21p Coda I Time In_ Time Out <br /> Business Rep Title -- O PM AM <br /> 0 PM <br /> 0-c �L <br /> Operational Status Tire Type , �, 1 Business Role Storage Type <br /> (w (Fill one only (Fill all that apply)', (Fill all that apply) (Fill all that apply)` <br /> Tire Count(Wh(oe/PTE) <br /> ® Active 0 Passenger Q Generator 0 Outdoor <br /> O 0 Closed Altered <br /> a <br /> GPS Latitude r 0 Hauler 0 Indoor <br /> Cid • —� 0 Inactive 0 Truck <br /> O <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> q <br /> 0 New Tire Dealer 0 Auto Repair (6 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 I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A j 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 M / M / m <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 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 ` ` r ` <br /> � j/G <br /> J 4` t_ �)Y �l✓� Ckrd', . n. , I?ill1., c" _ /L`I <br /> f l 1. r. ? <br /> [10 .e4df r`t' liIOri(t� f�( f_r'l�r:; <br /> - <br /> Inspection Form Included-: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> s° <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X �0 _ r 62081 <br /> ', ', -' ; <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> S" <br />