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Waste Tire Su & Inspection Re orM__ _-_Ipecton Report Number ■ <br /> ■ - u.331,. State of California '—-----. <br /> AATSA CIWMB 181(New 04/04) Survey Form - Page 1 1` 1 " <br /> - 1 0 1 3 7 6 3 <br /> California Integrated Waste Management Board _ ;. <br /> Part A Surve BLUE OR BLACK INK PEN <br /> M.• <br /> t , <br /> TPID- C !7wInspection Type (Fill one) <br /> Site Suffix: �' :C] > -inspection QReferral <br /> Q Observation <br /> Local Routine QRe <br /> If Referral,choose referral type(Fill one) <br /> Identifier: f <br /> l ('t J L' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name f % Inspected_.B. <br /> y <br /> Inspector <br /> Physical Address Eli <br /> DRi <br /> _ <br /> fu a <br /> Street <br /> f - Inspection Date <br /> ulty Mate S ?_lP Code>" Time In Time Out _ <br /> _..- -- <br /> Business Rep Titley f, F ® AM / AM <br /> 0 PM0P/ <br /> PM <br /> f, LlOperational Status Tire Type Business Roled r <br /> (Fill one only) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger Q Generator 06-41 <br /> — 0 Q Closed Q AltredGPSLatitude Q Hauler Q 1rhiI <br /> Q Inactive Q Truck <br /> C <br /> Longitude QO � <br /> a QPlanned TR Q End-Use Q C " <br /> �( <br /> t <br /> t�ua <br /> Business Type (Fill all that apply) i •at, m <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 / -1'= <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS ' <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q �PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> - Q Notice Of Violation Q Extension <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 (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 (a 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § Q In Compliance - No Violations <br /> Comments ! f t <br /> , � t`. c �i t t l C-( j,�., v'�: U X I _ r 1 I s <br /> rt,I 1t "� tff v i { �� .1 yF 1T � xt !'l- f•j; f�f. , <br /> '�C;;, {-E ti o) °r� r'y(Y, <br /> 1• i j i i. i _ <br /> Inspection Form Incl --- F a rr <br /> p uded Qi <br /> Comments Included: Qw <br /> Business Rep's Signature Phone Number inspector's Signature Phone'Nur'ber <br /> ' <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:,X °_ I 62081i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />