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■ Waste Tire Su y & Inspection Report,* <br /> Report Number ■ <br /> kaState of California Survey Form - Page 1 -- Q $ I <br /> CIWMB 181 New 04/04) <br /> California Integrated Waste Management Board _,. .. <br /> Part A <br /> u,r,a-,+.",,,rS;.�,r, "1�, r.r M,.,r.,;_3ix:.x�,.>.,'.. ✓"r, ,,,..n..' h;�r'._,,. ,�^td`.:.,y�„ �3t''?,r_ui,`3 <br /> BLUE <br /> LUE O+.^R BLACK <br /> �I(.N.�4K PE <br /> N <br /> 6`1, <br /> . „ 0510s112E T10 <br /> „ NINEt (t <br /> ✓---------- <br /> Inspection <br /> -,, ,.Inspection Type (Fill one) <br /> Site Suff ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> TPID- ix: <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. A0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> Physical Address [�T <br /> __j <br /> Street <br /> I IInspection Date EE� — <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title <br /> Q AMO AM <br /> O PM ��� I PM <br /> i <br /> Operational Status Tire Type Business Role Stor""' <br /> 5, 1k, (Fill one only) (Fill all that apply), (Fill all that apply) (Fill a <br /> n Tire Count(Whole/PTE) "v{ wrt'aPr1 JIi <br /> 9 Active 0 Passenger 0 Generator 0 Ol+tft �� <br /> rr krk+ <br /> D 0 Closed 0 Altered <br /> GPS Latitude 111 , EI <br /> 1 s'%ix'ta It{" <br /> Hauler Ind6r <br /> --- O 0 Inactive 0Truck,,. , <br /> Longitude - � 0 Planned 0 OTR 0 End-Use 0 Container <br /> Bts inesS.Type (!=ili all that app y) <br /> 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 HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <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,ED <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 (Pequired for NOV or EXT) <br /> i <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 /> ,4„4,i li,41q' ” ,n"q" No Violations <br /> 0 0 Other: § <br /> Comments r _ <br /> - L <br /> Inspection Form Included: 0 <br /> Comments Included: 0 _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> t' A �' i ! 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � � � -, <br /> ■ ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />