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:: . <br /> Waste Tire Suy & Inspection Report Inspection Report Number ■ <br /> IState of California A <br /> ®ala SurveyForm - Page1 � � 14 - � � 3 � 04 <br /> Xz9 CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> R s' pf <br /> Inspection Details <br /> ".`�4°°� Ems""i "+.emu�"��, 'n°�i r .k+.mw;•"r.e,k,&,uy�,,c�E2,: Lmk�r•*.cS.Pra�.er�a tr wk.,u. _ - _ . -_ <br /> T,�ID- Inspection Type (Fill one) <br /> --! ( , —7 - --- - <br />} Site Suffix: �! l i ll "1 = y Q Routine Q Re-inspection Q Referral Q Observation <br /> Local f �" If Referral,choose referral type(Fill one) <br /> Identifier. -�(,( V1 (��� t-�g:l �`� �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -- r. <br /> { Inspected By Inspector <br /> Physical}Address <br /> Street <br /> Inspection Date + ` ( EK <br /> City �'- State ZIP Code Time In 0 AM 0 AM <br /> _ Time Out <br /> Business Rep Title) O PM ^� O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> R& MOR <br /> y; (Fill one only) (Fill all thatapply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) a. <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> - _ O Q Closed Q Altered <br /> GPS Latitude , Q Hauler Q Indool <br /> Q Inactive Q Truck <br /> Longitude - ,�� Q Planned Q OTR Q End-Use Q Container <br /> r y,t>'y,y�",%yk`"°Mc" ,kr�'�k"r ✓ rF t ._, .k G _SII <br /> I 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 @ Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _ Y -- <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> ca: Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FTI / m / m <br /> Q Q 14 CCR§18459.1 (a)(b) (c)-Tire Program ID Number from CIWMB <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 /> In Compliance - No Violations <br /> Q Q Other: § — - <br /> Comments liU y <br /> i�`' { :r (i1r (► f J�t t�,I-}{ <br /> t <br /> Inspection Form Included: Q' <br /> Comments Included: Q _ - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> -' I <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X 'J "l ''�'._/" r,r - 62081 <br /> I IN ; t.l <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />