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Waste Tire SuAy & Inspection Report*.Inspection Report Number <br /> State of California <br /> - - <br /> ,'IS3iSS CIWMB 181 New 04/04 Survey Form Page 1 / <br /> alifornia Integrated Waste Management Board J ( f <br /> Part A-curve BLUE OR BLACK INK PEN <br /> - .jiBClpt1 P +a `mit w � air;• "ZMI i�t '4�r.2.u" {_ l,:r` _"_ .dna'. ,.._ ' .�,�,. n n' <br /> } <br /> "TP ID Inspection Type (Fill one) <br /> Site Suffix: �' ! Q Routine Q Re-inspectionObservation <br /> Local Q Referral Q <br /> If Referral,choose referral type ype(Fill one) <br /> Identifier: <br /> �` 1y-fit r `i. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - - - - <br /> ' Inspected By Inspector <br /> Physical Address- <br /> Street p <br /> ' Inspection Date _ <br /> l <br /> i <br /> city State ZIP Code Time In Time Out _ <br /> Business Rep TitleQ AM Q AM <br /> [_ ._� �_,_ O PM — O PM <br /> it <br /> Oypeerational Status Tire T Business Role Storage Type `= <br /> P <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)'. <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> r <br /> GPS LaO Q Closed Q Altered <br /> titude <br /> L _ Q Hauler Q.Indoor <br /> 0 Q Inactive Q Truck <br /> LongitudeQ Planned Q OTR Q End-Use QContainer <br /> Business Type (Fill all that apply) - <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 /> 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 /> 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§42956-Registration/Decal in Vehicle <br /> Q I Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m m <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 /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q In Compliance - No Violations <br /> Q Q Other: §L <br /> Comments /� f� _ <br /> Ott <br /> ��} --�,i <br /> - �(. Lf'' 7lG <br /> TI-1I` ros � ` 1�t ��) G'fCtf(J%1 C _ it o r k(t To(-o - yi1 o')C - �4�C, <br /> n <br /> J <br /> Inspection Form Included: <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X - 62081 <br /> ■ ® ■ <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />