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Waste Tire S�y� Inspection Repo T <br /> S ction Report Number <br /> State of California <br /> CIWMB181(New04104) Survey Form - Page 1 - Oj <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- Inspection r Inspection Type (Fill one) <br /> I Site Suffix: 1 L/� � + � I CJ / 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ^ T t If Referral,choose referral type(Fill one) <br /> Identifier: !(�t 1 �(,�i1 ilt -- '`i 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Namet. <br /> iInspected By Inspector <br /> tti`i�t�L f t' lick I,-t✓I S;rVI,G- _ I {' - <br /> Physical Address ✓ — 1 �) <br /> Street t <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title (3 AM <br /> � J L� Q AM <br /> 0 PM / �/ ! 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)', (Fill all that apply) (Fill all that apply) <br /> MINNIE= ® Active 0 Passenger 0 Generator 0 Outdoor <br /> I <br /> GPS Latitude <br /> Latitude m . 0 Closed 0 Altered <br /> 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — LIJ1 <br /> 0 Planned 0 OTR 0 End-Use 0 Container <br /> 0 New Tire Dealer 0 Auto Repair ® 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 /> i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS =- <br /> V A HRC LING AND MANIFEST <br /> ST REQUIREMENTS oandTrans ort of Tires 0 Notice Of Violation 0 Extension <br /> 0 O § g P <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 & 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments p� ' <br /> f AC �,t�. ;{fJt' �?/ <br /> ��(�f t1t'tt qty( _.Ct r� 1:ic�/r�lYL ,�'CE1 01 L{Fi`yljkld�ll.t,t�f i_ Vii' ifl�i (� j)_ .tl�;yY{ (< j <br /> /� 1 , r1� / <br /> )fk' it,:ii"j d.{r Jr�if! (t ilk Ut e`-ii `' V�/�I. < YZ �� l �l iJ/'c :d,{{t <br /> w�fv dor �t /r•:..r; j� fi�;,� �r �,�-� <br /> Inspection Form Included: - <br /> t <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X E X A SIA F L1112L3' <br /> '3zoa1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />