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Inspection Report Number <br /> Waste Tire Softy & Inspection Repor <br /> 1033 State of California <br /> i{ 0 <br /> CIWMB 181(New 04104) Survey Form - Page 1 .,1 9 - 10 10 5 5 9 <br /> California Integrated Waste Management Board ---- --.- ---- <br /> Part A- Survey BLUE OR BLACK INK_PEN <br /> Inspection Details <br /> TPID- jj Inspection Type (Fill one) <br /> Site Suffix: - C <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local ;-! If Referral,choose referral type(Fill one) <br /> Identifier: 0 Jl U{l le l ( ii((l;'Cf Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name`- <br /> Inspected By Inspector <br /> De <br /> L J"_� 4, y 'A <br /> Physical Address3 3, !! /� Q <br /> I <br /> Street <br /> J ,/ f !�LP Inspection Date <br /> _j <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> CQ ' m0PM � ' 0PM <br /> Operational Status Tire Type Business Role Storage Typ <br /> Tire Count (Whole/PTE LIiiiiiiL% (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that ap' <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altere <br /> Latitude <br /> GPS �J Q Hauler Q Indoor <br /> - O Q Inactive Q Truc <br /> Longitude - Q Planned Q OTR, Q End-Use Q Container <br /> Business Type (Fill all that app <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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST' REQUIREMENTS - 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: § <br /> Comments <br /> f i <br /> Inspection Form Included: Q <br /> Comments Included: Q' <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Numbe <br /> � �� <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect: X \/ a ,d l I P I L I E 1 2 3 62081 <br /> White Copy:CIWMB Yellow Copy Operator Park Copy:LEA <br />