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AWaste Tire SAly 8c nspection Repor Inspection Report Number ■ <br /> State ofCalifornia <br /> eaaa CIWMB181(New 04104) Survey Form - Page 1 L - 10 0 6 7 7 3 <br /> California Integrated Waste Management Board _ ...i <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Id?ip <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix I J I J �' `Q_.. I (0 Routine Q Re-inspection Q Referral Q Observation <br /> - [E <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: y\ V(tT (,t t:1 01K KI int_ Y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 7) f <br /> Street - <br /> t` <br /> r- �' / Inspection Date r <br /> ' 5rJ110/1 <br /> =' <br /> - Time In Time Out <br />� City State ZIP Code <br /> Business Rep Title O AM _ <br /> O AM <br /> Lou : C�SPM [5 � O PM <br /> i �N Operational Status Tire TAYi 'r °a�W Business Role Stora e Type <br /> (Fill one only) (Fill all(11 (Fill all that apply) (Fill all that apply) <br /> Tire Count(WholelPTE) AE Q <br /> - � 0 Active Q Pa A (0 Generator Q Outdoor <br /> O Q Closed Q'Altere#y'�>� <br /> GPS Latitude / Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Q Planned Q OTR <br /> � .n, <br /> Longitude - , I � Q End-Use Q Container <br /> ,�airt r[ <br /> __.,,Q` <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 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 /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> mm / m <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> (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 Q Referred i CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q O Other: § <br /> Comments n . <br /> CA <br /> r . /' <br /> Lf i'd edit (Art I I�7 ('7, Y�I <br /> !. .!I-"iC Y,)Lt C' S , _i'+�:t (i ij C5 It )trc-{ . r 1 <br /> Inspection Form Included: Q, <br /> Comments Included: Q _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � �/ ;a A 14r r , L I � 1 <br /> ■ White Copy:CIWMB Yellow Copy:Operalor Pink Copy:LEA ® ■ <br />