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Waste Tire Su- , y & Inspection Report Inspection Report number <br /> State of California ►�^� n <br /> CIWMa181(New 04104) Survey Form - Page 1 i - 1 V�nf 0 V V 0 <br /> Califurveyornia Integrated Waste Management Board <br /> - SBLUE OR BLACK INK PEN <br /> Part A <br /> Business Profile Inspection Details <br /> TPID- i Inspection Type (Fill one) <br /> Site Suffix: 1 Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sa" JC�� c �y� ��,� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or <br /> Facility Name \v` Inspected By Inspector <br /> Physical Address <br /> ` ' 1 Inspection Date G L, \-Vv. L�3 <br /> Time In Time Out <br /> Business Rep Title ® AM ® AM <br /> ._ l2 O PM 3 `� O PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> (Fill one I (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> ® Ac' ._ Q Passenger Q Generator Q Outdoor <br /> 0 Q Closes Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inas: ;e Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Pla--ed Q OTR <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 <br /> ® Notice Of Violation Q Extension <br /> ® 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 Require-tints Date \ V <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 (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> ---- - <br /> —------------------ ------------ <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> i <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End Use Facilities <br /> - - -- <br /> Q Q ---- <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments \ t ( { <br /> \� vib� t��tG� �L.��✓���7 v`VOiL.L ~rc� �� \�l1'T <br /> t�u 5 �u �� a�5 o�l�.t Z `� `tom S l� U-7 1,\C�55 <br /> Inspection Form Included: Q tig�atur. <br /> Comments Included: QBusiness Rep's Signature Phone Number In pector's Phone Number <br /> ` , <br /> INSTRUCTIONS ON BACK Correct: Incorrect: x � E X R M Pi L E 1 2 62081 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />