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spection Report Number <br /> Waste Tire S^ & Inspection Repor ■ <br /> GaA State of California i s rs n n <br /> CIWMB 181( e ) vey Form - Page 1 a �r t <br /> r 5 ty <br /> California Integrated WasttManagement <br /> Sur <br /> Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Sustnes I�ra'it" i Jill It iii <br /> rsPtrct�on t? tarls y-. <br /> L.� �� f l M <br /> Inspection Type (Fill one) -- <br /> Site Suffix: 1� 11D] ® Routine Q Re-inspection Q Referral Q Observation <br /> Local J i – If Referral,choose referral type(Fill one) <br /> Identifier: (�� ��� ( f{,•t.til iA; .� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I El Inspected B p y Inspector <br /> LLL <br /> Physical Address <br /> Street ( <br /> Inspection Date <br /> City State ZIP Coda Time In Time Out., <br /> Business Rep Title 0 A 0 AM <br /> J0 PM � 0 PM <br /> Operational Status Trre Type Business Role <br /> v (Fill one only) (I IIf;aN thata ly) (Fill all that apply) , <br /> Tire fou t o� <br /> ��� ,„�.., � <br /> ��, i <br /> ^' ” JActive Q Passeneler . Q Generator <br /> GP$ <br /> Q AlteletlLatitude QClosed <br /> Q Hauler <br /> LLI L10 <br /> . <br /> Q Indo: <br /> O <br /> Q Inactive (`Truck <br /> Longitude – Q Planned Q'OTR Q End-Use Q Container <br /> Business Ty Y' — <br /> Q New Tire Dealer Q Auto Repair @ 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 /> —AFH—AU 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 -Tire Program ID Number from CIWMB m m EEI <br /> Q Q 1 14 CCR§ 18459.2.1 -Submittal of Comprehensive TJ within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive 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 f/l 1 <br /> llJf�l <br /> LA� '•" t'V j f ;/i 1��/Gt q �I re- J4 � /�i(t ai v` ✓I Ct _i <br /> V(!'v;1 n;.I ,k o r y-dk1 C t(l;f Ijo d lc; k. <br /> rrrd w.,•r. , w µ ea i ,f � a ' i � a «m-h"�. �,,n r V � y.._� �t �i r"� 7�5�. t ,k..., i;�k r �,+f, �M N <br /> In�sp� <br /> I Business Rep's Signature Phone Number Inspector's'Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:; Incorrect. ;. ` ) , J .1 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />