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ff <br /> pection Report <br /> Waste Tire S y & Inspection Repor�SNumber ■ <br /> CIWMB 181(New Surve Form - Page 1 - 1 3 7 a 3 <br /> { 1 <br /> California Integrated Waste Management Board Y � �..._..._ . <br /> Part A- Surve r BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: f j / '' f �% { I Routine Q Re-inspection Q Referral Q Observation <br /> Local rte. — I _ If Referral,choose referral type(Fill one) <br /> Identifier: t`• <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address - <br /> Street <br /> t Inspection Date ✓: I r / ) ; <br /> City State ZIP Code Time In Time Out <br /> Business Rep0 PM <br /> Title 0 AM } ' 0 AM <br /> 0 <br /> PM <br /> Operational Status Tire Type Business Role Storage Type <br /> ..., , <br /> ,-` ' (Fill one only) (Fill all that apply)', (Fill all that apply) (Fell all that apply) <br /> ..Tars Count (�lllhols/F'TE) �} <br /> jo Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS�-Latitude ( . HQ Hauler Q Indoor <br /> o <br /> Q Inactive Q Truck <br /> o1—,_ —_ 1 7-7-7 <br /> _ _ O <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <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 a 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m 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 Q In Compliance - No Violations <br /> Q Q (Other: § - <br /> Comments. <br /> t V - 1' t _ 1 / �_� l— 1/��1 t t� `; �/Ili,P "t <br /> I r ,{ r�� rI _ C,(. .c; alt.) / 11l i 1 �tt— /4tJ } <br /> J. <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 7. 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: XA I r+, m, i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.'LEA ® M <br />