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ii <br /> ■ Waste Tire Su Aril ection Re Ort ion Report Number <br /> p p -- ■ <br /> State of California - <br /> — -- <br /> _r� CIWMB 181(New Manage) Survey Form - Page 1 ET California Integrated Waste Management Board � <br /> Part A Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Ifi13yty�,+},r I£ �rojr w J 1 w{ r k iwf r a' reM a <br /> .. 't _:„ .. ;:. r«l., i._J.N�t "itiw•d uS� �,»;,t�`„" ?1� 4rr y 1)�`y./ 7 y 'h.:' '� tk ' M'�"�� uMa,1�f 4 i <br /> TPID- -- - .. r�.�u.._�t„ r. )�.��.trr,rf ru4 <br /> Inspection Type (Fill one) <br /> Site Suffix: ] 1 r ✓ <br /> �'" O Routine Q Re inspection 0 Referral Observation <br /> Local f'. f-! If Referral,choose referral type(Fill one) <br /> Identifier: ' <br /> O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name — -- - <br /> _� Inspected By Inspector <br /> Physical AddressLj <br /> s — <br /> Street / <br /> Inspection Date <br /> L ( `7. 4 J <br /> City State ZlP Cvde I Time In Time Out <br /> Business Rep Title AM <br /> �) v t �`1 rte) ® PM <br /> _ IS AM <br /> -- <br /> QPM —_I ' Q <br /> r, . Operational Status Tire Type Business Role <br /> r, g1� faCh jT� (Fill one only) (Fill all that apply)' (Fill all that apply) ` (Fill'afl that apply) <br /> Punt ( <br /> ` ® Active 0 Passenger � Generator Q Outdoor <br /> I <br /> G pS Latitude O 0 Closed 0 Altered I <br /> Q Hauler Q Irlel6or <br /> — —,0 � Inactive 0Truck <br /> Longitude <br /> _ <br /> Q Planned 0 OTR Q End-Use Q Container <br /> 'T pBusiness Type (Fill <br /> aah <br /> Q New Tire Dealer 0 Auto Repair O Trucking Fleet O Government O Retread er O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder (jo Other i / . <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> --o __ -- — — Notice Of Violation O Extension <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> Q Q 14 CCR§184.59.1 (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 0 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ( § <br /> Q In Compliance - No Violations <br /> Q 0 Other: <br /> Comments <br /> VJ(J'' <br /> 11-t C <br /> �. 0 f �. + C` V 7 /T �' ' 4 ( P C� �,.•�l f f ) I.'-./ ! 7 <br /> ! j <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 BAC/Kite Coor MB incorrect:Yellow copy:operator <br /> ■ <br /> Pink Copy:LEA © ■ <br />