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inspection Report Number <br /> Waste Tire SL �y & Inspection Repor, <br /> -'•�7a1 State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 i 9 - 10 0 6 6 6 4 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: S� c> Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5a ;02W�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 7a C_ \ t"�.K S <br /> Physical Address <br /> CA <br /> _ Inspection Date <br /> Time In Time Out <br /> Business Rep Title p Z r O AM O AM <br /> PM U 3 •5 ® PM <br /> vvw^3 Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)'. <br /> 1 f � <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 ® Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> D 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 1 HAULING AND MANIFEST REQUIREMENTS <br /> 0 00 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV orF_X7) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years . . <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred i CIWMB Enforce, e <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 ®In Compliance" No Vwlatlorts <br /> 0 0 (Other. § — --- -- 6. <br /> Comments \\ l_ 1 <br /> AA- T\/\1-5 5A< <br /> 1 r'C <br /> \ 1�u;��5 - a•�� ( \cL;� S- <br /> -�� „N o W w'j 1-c `1.c��,� t "ICi 5 _ C-a � C'-VK � Y`�\�� �G kw <br /> jz> <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - - - - - <br /> Business Rep's ignature Phone Number Inspector's Signature Phone Number <br /> - —--- ------------ <br /> 62081 - <br /> INSTRUCTIONS ON BACK i Correct:_ Incorrect: --/ E_X /t JCA P L Ei 1 Z 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />