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_ Waste Tire Su. y & Inspection Report <br /> �nspectionReportNumber <br /> w 04104) <br /> L:. _ <br /> `li>5I State CWMof California A jp�i <br /> California Int grat d Waste B 181 eManagement Board Survey Form - Page 1 ~�' - V <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> p Inspection Details <br /> TPID- O - l Inspection Type (Fill one) <br /> Site Suffix: 15171 10 1* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: r1 � -vE 'k o 0&-R , ` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> �.t 1 Inspected By Inspector <br /> a l i -(y Lt C <br /> Physical Address <br /> Street <br /> C ; _ Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> til ' +� PLA(A <br /> m • O PM O PN1 <br /> i— Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that ap (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passeng ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude EEd Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned OTR• Q End-Use grata!: c <br /> Iiii—Business Type (Fill all that appt <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 (J) Other r. <br /> -- 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 /> --- 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 /> 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: § J <br /> Comments 11 <br /> 1:tJt �tr t 1� C �t�.� c �: , ;-,�-c•h l_, �,�:cl���.�>✓_��t r lot rE <br /> %!C� 1'Yla�t��e�;� ��`` u<_��,.C . -Tf 5 /-c Acc.<t_c�c� fir� �alabt� <br /> Inspection l`orm Includ ]MMOMW <br /> e ` <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature _ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X i L; A i A 0A iPILIE1 III2 3 <br /> White Copy:CIWMB Cnpy 0:,:ator— Pink Copy:LEA <br />