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Waste Tire Suy p p p p <br /> r� & Inspection Re Ort Inspection Report Number <br /> State of California <br /> CIWMB 181(New nage) Survey Form - Page 1 9 0 1 <br /> California Integrated Waste Management Board g -10 _... --. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Uslhe ;PPet <br /> TPID- ( Inspection Type (Fill one) <br /> Site Suffix: ( l r ' , ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> Physical` AddressF <br /> i <br /> Street \l Y <br /> Inspection Date <br /> City � StateTime In Time Out. ZIP Code —_.. ......._. <br /> C <br /> Business Rep Title O AM (, ®AM <br /> OPM PM <br /> Operational Status at, I� � rft G,, Business Role <br /> / (Fill one only) (Fill(Fill all that apply) <br /> ® Active ;+' 9 � Generator Q" f�xllgpt <br /> G — Q Closed <br /> LatitudePS <br /> f�r~'' <br /> I ® Hauler <br /> Q Inactive <br /> Longitude Planned0 End-Use <br /> ELLLL <br /> e <br /> +r+ ,u yr�+ r z--,�'°,*�' t;+�r kµ�,..�� �,�'r r ��"� �t1��.-rz✓.y<, <br /> R6 <br /> ,:- r�" ..u..",w�..r '".. <br /> @ New Tire Dealer a 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 HaulerQ Agriculture Q Shredder Other j`, <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 Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 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 <br /> Q Q 14 CCR 18459.1 Oa ( )Oc Tire Program ID Number from CIWMB FF1 / FT1 <br /> FTI <br /> 1, <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV orEXT) <br /> QQ 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years �� r <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulersie �fR( tltAt <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> �� �a •c 6 � f, �r d F � �� ~�� <br /> e � "wtP A , + <br /> Q Q 14 CCR§18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators + �f �tr, f <br /> Other: iu{ r <br /> § �,„ ,r <br /> Comments , <br /> Correct: Incorrect: v <br /> - ._.. <br /> INSTRUCTIONS ON BACK !y, E _� _ e1_2 62081 <br /> ■ White -- - ® ■ <br /> Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />