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Waste Tire Sulty & Inspection Repo nspection Report Number <br /> StatT 1 j(y� ��^y+ /��( <br /> CIWMB <br /> fl81(New - Survey Form - Page 1 + + O v v V <br /> ' CIWMB 181(New04/04) <br /> California Integrated Waste Management Board <br /> Pah A- Surve BLUE OR BLACK INK PEN <br /> w:::/"' t Y/u S- 'v '''"%""";: "' F u, r,...✓,r/w'�" a �r' r ✓ r/ <br /> TPID-,. r F_ — � m Inspection Type (Fill one) <br /> 1 <br /> Site Suffix: _ti Q Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -- <br /> Inspected By Inspector <br /> t r/ <br /> Physical-Address <br /> Street, f <br /> ( Inspection Date <br /> Time Time TimIn Tme Out <br /> City -- - State ZIP Code <br /> LF , _�.,._ _Business Rep Title 0 AM Fjj (0 AM <br /> I`— <br /> ,Tv Operational Status art, w Business Role <br /> 1 � <br /> (Fill one only) lt t (Fill all That apply) <br /> cr°✓ �� ✓ u i%�•. �"✓� f /,�' ✓✓ n�Mu ly(My"'yMy�G a de) ', ,r <br /> r ,� i a� u3/k'✓�a"�y+r�r�� �'� r�err � '?,�° <br /> Q Active n ) Q Generator i <br /> - • __p qtr / r��� '��"� l r,� �I <br /> Latitude Q Closed <br /> IIr n t <br /> GPS Q Hauler ohr <br /> O Q Inactive <br /> r7 / a 1 " e ✓ <br /> Longitude - Q Planned � trr � �r"'✓ m 0 End-Use <br /> y <br /> �USft1 $,��Y�t?��� f � �r��rr�lF�t"s�r^ r � �r +�. �� � �l„u�' r r �� ✓g� .wry �reR��� rot, <br /> � 'r �'^rrh.�lli._ %.,- A,n. ,:a: Y.x3" /' .9°.„ X,rr A w ,.. ✓. ..✓..d,u.v' r .�'�.i�L` l r ��4v w b A�. m ., � "�%Lx�,+.' �k0✓wYr P, 9 u`X7„r� i�o�<h,�N n'lM <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Service Station Hauler <br /> Q ® Q Agriculture Q Shredder Q Other <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENT$ <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§4,956-Registration/Decal in Vehicle <br /> Q 1 Q 14 CCR�18459 -Responsible Entities Complying with Manifesting Requirements Date IE <br /> Q Q 14 CCR§\1\8459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q Q 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance '- No Violations <br /> Q Q ,I Other: § <br /> Comments l <br /> Inspection Form Included: Q - - — <br /> Comments Included: Q� <br /> Business Reps Signature Phone Number Inspector's Signature Phone Number <br /> _. - -_ - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ' �. �4x <br /> L-.�1 A rfIt � �� 1 + 2 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />