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Waste Tire Sufty & Inspection Reporlalnspection Report Number <br /> State>n� <br /> CIWMBf 81(Nrnia Survey Form - Page 1 - $ <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board - - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Detail EIIIIIIIIMIM <br /> TPID- In <br /> spection Type (Fill one) <br /> Site Suffix: ! 1-2 4kf 6 [Kil ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. ^, .�Gt�;� ��.� � � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 1 <br /> Physical Address C,7 31 l Q I �� <br /> Street <br /> / Inspection Date <br /> I <br /> City State ZIP Code� t - t � J�1 yQ Time In 7 Time Out o <br /> Business Rep Title AM 0 AM <br /> 0 <br /> m <br /> I PM / ,� QPM <br /> Operational Status Tire Type' Business Role orage Typ <br /> jL T (Fill one only) (Fill all that apply) (Fill all that apply) ill all that app <br /> Tire Count (Whole/PTE <br /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude m . 0 Hauler 0 Indoor <br /> D 0 Inactive 0 Truck <br /> Longitude — 4 0 Planned 0 OTR 0 End-Use 0 Container <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 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 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 or EXT) <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/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 I Other: § <br /> Comments <br /> �,lis arc.., � r+r �',,.»r_ • �,/� � -;�� 4 �., vPAO ��'�- _ ���_— <br /> Inspection Form Included: 0 — <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> X � � MA LIE! 62081 <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect: � �'"�( ft ,., P � � � � � <br /> White Copy:CIW NIF raspy:Ot,erator Pink Copy:LEA <br />