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f.' <br /> Waste Tire SPoey & Inspection Repo inspection Report Number! <br /> _ __. <br /> State of California f1 w <br /> c CIWMB 181INew04/04) Surve Form - Page 1 100 0 0 5._. _-.._6 , <br /> California Integrated'Waste Management Board Y _..... _.__ _._ <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 -�� C', Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address `j — ( -# <br /> --L-- ' fir' 1c,�1 <br /> y`! <br /> Street <br /> _ Inspection Date <br /> ` 7 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM F Q AM <br /> QPM '_� � C__ _ QPM <br /> I tAll Operational Status Tire Type „a t•„ Business Role Storage Type <br /> " ,�` (Fill one only) (Fill all that appior (Fill all that apply) (Fill all that apply):: <br /> Ire' ""ount b;Y1 h61e/PTE) a a Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 <br /> Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 Inactive 0 Tr, <br /> O <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> x' 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> r 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ', Date M / M / m r � <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> iii Ig 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br />'{ t 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § - <br /> Comments <br /> 1 t ✓C(` T 1s r= lz/c^. c1�1lf_' l �— <br /> / % / r ' ys Y r1` T_ c�.i C >���t•P� CJc?r-A ..Y <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: V ". :�' <br /> _..._ <br /> ;1 ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />