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Waste Tire Surly & Inspection ReportInspection Report Number ■ <br /> . -,.q■ T State of California <br /> 4:z4, CIWMB 181(New 04/04) <br /> Survey Form - Page v Q�_ <br /> California Integrated Waste Management Board - -- - <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profiletrection Details <br /> - - <br /> TPID- Inspection Type (Fill one) <br /> f / - <br /> Site Suffix G� / >� b p / Routine Q Re inspection Q Referral Q Observation 11 <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J�.y� �if:�a r-c� C _�yL;�,. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name T Inspected By Inspector <br /> _T, -1 1// <br /> Physical Address <br /> Street / <br /> L�Inspection Date , IIII---J---J <br /> tt, State ZIP Code Time In _ Time Out <br /> Business Rep Title l / /� AM <br /> 0 PM 0 PM <br /> 16 <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply); (Fill all that apply) (Fill all that apply)'. <br /> � 1 <br /> Active Q Passenger I, (jo Generator Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude t — Q Hauler Q Indoor <br /> _ _--t-- Q Inactive Q Truck <br /> �D Q End-Use Q Container <br /> Longitude - Q Planned 0 OTR <br /> Business'type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trl eking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Carbealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder (j) Other _'y _j <br /> � /e :Gsi. r <br /> ?t � <br /> i p (FEST REQUIREMENTS „ <br /> Part B - Inspection of Waste Tire Dealer Generator Hauler and End-Use FacilityENFORCEMENT STATUS , <br /> V i A HAULING AND MAN Q 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 M / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Re <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days ( "q ) <br /> uired 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 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q 14 CCR§18462-ManiQ In Compliance No Violations <br /> Q Q Other: § <br /> Comments <br /> / !-� �.yO ,f•:�!`ti,d r:;7� l G:� ; �� r v v � `fir <br /> ./ r"f l r'� (T �,' ! � � ( .':L 2.P' fJ:i— '! �/_. "/ < .j�f' :—<,.�I l� c" J4!�F'.r il.' —^•'--'•_ <br /> f C- <br /> Inspection Form Included: Q', <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number , <br /> 62081 <br /> /,r 1-. <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: �('\ "f, � "" . <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® S <br />