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Waste Tire S & Inspection ReporWrion Report Number„ _ L.'C�3a State of California +t ON ��s >, CIWMB181(New04/04) Survey Form - Page 1 0 13 7 � � <br /> California Integrated Waste Management Board - - <br /> Part A- Survey <br /> BLUE OR E3LACK INK PEN i <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: j t (41 Routine O Re-inspection O Referral O Observation <br /> Local �' If Referral,choose referral type(Fill one) <br /> Identifier: t t y f O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name { ; Inspected By Inspector <br /> Physical Address L F/T <br /> VV, <br /> J tC � <br /> Street Inspection Date <br /> L <br /> City _ State ZIP Code Time In [_1 <br /> Time Out <br /> Business Rep Title , 0 AM O AM <br /> - - <br /> 4 ,- <br /> `ll v h <br /> Operational Status Tire T r, ;„: Business Role `,Storage Type <br /> p yA <br /> ” (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I <br /> ire i.ouni'Whole/a TE) m` <br /> ? (a Active O Passenger O Generator O Outdoor <br /> ]0 OClosed 0 Altered <br /> GPS LatitudeF1 O Hauler O Indoor <br /> ��11�� O Inactive O Truck" <br /> O O End-Use O Container <br /> Longitude — O Planned O OTR <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer 0 Collection O Crumb Rubber <br /> J'f <br /> O Service Station O Hauler O Agriculture O Shredder s Other f�,� 1 j h( ✓`t r1.✓-i 1.,t I(;? <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V q HAULING AND,MANIFEST,REQUIREMENTS _ O Notice Of Violation O Extension <br /> O O 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 /> O ' O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> - I <br /> O 0 <br /> 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 O Referred t CIWMI3 Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities -_ <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O Other: § _ <br /> Comments <br /> r <br /> t , <br /> YYa({/ r( 1it'rl.tl lttr2 ' YE 1 't #!t�' <br /> E1 <br /> f. , ; � I '%r;' .I�C%f'i ;{"'t�' �t�Gtt�1t j7ti l ,y�r� •� ,;i .l r'!rt `_ 1 .jt.7( f(/ . y/,'/il r t/I �� <br /> — - i <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:I Incorrect: X <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �^ ■ <br />