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nspection Report Number <br /> ,Waste Tire Su y & Inspection Report ■ <br /> LuS� - State of California � }J�'�� <br /> CIWMB181(New 04/04) Survey Form - Page 1 1 G 1 0 V 4 <br /> California Integrated Waste Management Board C <br /> I; Part A- Surve ( BLUE OR BLACK INK PEN <br /> fi" t *"� 0 <br /> 9_..sci °, r, <br /> ✓ a TPID- ` Inspection Type (Fill one) <br /> Site Suffix: t o r ! O Routine O Re-inspection O Referral O Observation <br /> I -AL <br /> -_ - <br /> Local f If Referral,choose referral type(Fill one) <br /> Identifier: Y V\ > 7 L. O CHP O CIWMB O Complaint O Educational Visit 0 Other <br /> Business or Facility Name - Inspected By Inspector <br /> Physical Address <br /> Street Inspection Date <br /> Time In Time Out <br /> City _ State ZIP.Code — <br /> Business Rep Title !_ '..v Lj]] <br /> Q AMOAM <br /> 0 PM `l ® PM <br /> 1 4. <br /> Operational Status �, ,M Business Role r „ <br /> (Fill one only) I�ia st��11 (Fill all that apply) 'f�r+( ItJn���p } <br /> Active <br /> O ��� 1� O GeneratorMOLLL <br /> b <br /> O O Closed � �C � t <br /> CIPS Latitude Uler <br /> Ol��w''r `aereq,,+ry <br /> InaCflVe � qx +r"�, ty r�. �r•� p �5 r'x`;t, k <br /> Longitude – O Planned i,k t 1 O End-Use ttd � <br /> O New Tire Dealer O Auto Repair # Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O 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 /> O O 0 Notice Of Violation 0 Extension <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 /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m m <br /> / ,m / W <br /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ _ —_- <br /> O O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O <br /> Other: § _,__... _ n.,...__ _ Ti �Cp�plt h W NQd � a <br /> Comments <br /> : <br /> ,x <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: bra m' I 6 L <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />