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ja <br />State of <br />WasteaTire S y &Ins ection Report <br />Inspection Report Number <br />CIWMB 181(New "'o4) Survey Form - Page 1 1 4- 10 14 l 86 <br />California Integrated Waste Management Board 1 <br />'art A Surve BLUE OR BLACK INK PEN <br />MM <br />TPID - Inspection Type (Fill one) <br />Site Suffix: (b, Routine 0 Re -inspection 0 Referral 0 Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: a O CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />4. <br />Business or Facility Name Inspected By Inspector <br />(Physical Add ess <br />4,5 <br />Street f <br />Inspection Date © r <br />�L`�t��'_ �/� ��Time In Time Out <br />Cit State ZIP Cade ___� <br />Business Rep Title AM m AM <br />0 PM <br />i, <br />Operational Status y , � �a i�� Business Role <br />Fill one only) (Fill all that apply)) t ✓1 �I�i <br />Active (,Generator <br />Q ClosedGPSLatitude <br />[==o <br />"� !� Q Hauler 'r <br />O inactive �I y r v t.,. r igx�t✓✓ , "� <br />Longitude O Planned End Use <br />.�, i°,�'1^a ¢. + NfJ'�,r rn � f ?d ,:r l'" 1� :a+ u + ri✓.'".mriti ya ur ">f '�✓ �Sr "Y✓„»'H�"�.. ?��R' i>�d? �^x r..r p i <br />BaS[ne€ r�ili�� f p,r k n H n , 1 c t ' E / Ay lime yf� .mower <br />Q New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government O Retreader 0 Dismantler O Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection O Crumb Rubber <br />O Service Station 0 Hauler O Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility ENFORCEMENT STATUS <br />V A HAULING AND MANIFEST REQUIREMENTS <br />10 Notice Of Violation Q Extension <br />O O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O O PRC § 42953 - Contracts with Registered Waste Tire Haulers. Compliance Deadline <br />O O PRC § 42956 - Registration/Decal in Vehicle <br />0 0 1,4 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements Date <br />14 CCR 18459.1 a b (c) -Tire Program ID Number from CIWMB MCI <br />m <br />00 <br />§ OO <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 />0 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 0 Referred / CIWMB Enforcement <br />0 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 0 14CR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br />0 0 oth : § <br />Comments <br />-1 - - ._ - k"7 <br />Inspection Form Included: 0 <br />Comments Included: <br />Business Rep's Signature Phone Number Inspector's Signature Phone Number <br />62081 <br />INSTRUCTIONS ON BACK Correct: 4, Incorrect: <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />