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j Ins ection Report Number <br /> Waste Tire Surly & Inspection Report -_ — p __ _ __- _- _ _ . <br /> kaStateBCalifornia Survey Form - Page 'IF1006 3 2 1 <br /> CaliforniaCIWMB 181(New 04104) <br /> Integrated Waste Management Board <br /> Part A Surve BLUE OR BLACK INK PEN <br /> a n r. � rm+„µ <br /> r u„y "...; w ' '' � a r'rMII`1Zi't L r r <br /> '" "._.a,_ ., r pG t'^*"rM d ,eu�,.,x'�iw�r'r4, °�".� .�=.,�„a. <br /> TPID- _ ! Inspection Type (Fill one) <br /> Site Suffix: C..• �-7 (D Routine Q Re-inspection Q Referral Q Observation <br /> J <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> -_ — - <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> ` <br /> ( 'r <br /> '­ 6� - <br /> Street <br /> r. Inspection Date <br /> Cit State ZIP Code Time In Time Out <br /> Business Rep Title LJ <br /> I <br /> : FU_ <br /> O PM m . O PM <br /> r ,9 Operational Status Business Rolei <br /> t (Fill one only) r t (Fill all that apply) ( � <br /> f” v . Active � �� (je Generator „� r <br /> O Q Closed ` 1 � „�", <br /> GPS Latitude Q Hauler <br /> Q Inactive <br /> o Qnd Use <br /> Longitude - Q Planned <br /> '�? � i' tt,: I't t Y t Y r'� r i r}»t�'a �°'" r, �� ;r a Y�•: r„. C r °A w+� 'wy:tiq r irly 5 % �r{:,t,�r {^r '�,:a�t 1 r,.wr_-i. ,� ';� r r ��t,�:.y�.t.iN�'"�.."�,�i <br /> .:. Tire Dealer - air Auto Re .,.�.� J��r```"`,�....u, w�r, ,.r;�. ,._.�.,. �w..r�.,. . ,.�.--- .. ,..��.��•�, -a���r...N�n" � ,,.�.� <br /> Q New Tiea> Q p 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 /> ---- <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 /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FTI / m m <br /> 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 <br /> (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 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 O Other: § rrr <br /> Comments <br /> - r <br /> Inspection Form Included: Q <br /> Comments Included: Q. -- - - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 'il 0�0 '. 1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> j if. <br />