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Waste Tire SuAy & Inspection Fie Ort nspection Report Number <br /> ■ " .:�igID .4tate of Californias J 1— p .� .+� /Z <br /> CIWMB181(New04104) SUrVe Form - Page 1 .� I U $ 2 2 --� <br /> _ Y 9 <br /> '- California Integrated Waste Management Board ----- ��------ ----- � - <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business'.Profile w,n �mzm �r '^"'-'-"""i 't'�%��Is'M" ."t 7 ti ��. r '�• .�1. .,. .., <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I ' 1�. `� ( 1 ( _J , Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> r— <br /> Street <br /> Inspection Date / J� k <br /> city State ZIP Code rTime In Time Out <br /> Business Rep Title I AM <br /> O PM {- i_ V 0 AM O PM <br /> L L_� J <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Ril all that apply)�'�, (Fill all that apply) (Fill all that apply) <br /> Tire CUunt(Whole/PTE) - <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> mEEK <br /> D @ Closed 0 Altered <br /> GPS Latitude IZ�1 0 Hauler 0 Indoor <br /> F <br /> ������ D Inactive O l ruckLongitude – �� . 0 Planned �1 pTR0 End Use 0 Container <br /> 111 <br /> Susir;o ys Type: (Fiil ail that apply <br /> j 0 New Tire Dealer 0 Auto Repair 0 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A j HAULING AND MANIFEST REQUIREMENTS 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 <br /> 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 <br /> 0 In Compliance - No Violations <br /> 0 Other: <br /> Comments <br /> Inspection Form'Included: 0 <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ® 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: , \/ k.Wm ,w taa 1 I 131 <br /> ■ White Copy:CIWMB Yellow CopyOperator Pink Copy:LEA <br />