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i <br /> ` Waste Tire Su & Ins Inspection Re ori Inspection Report Number <br /> *. <br /> HIiI- State of California .. <br /> CIWMB181(New04104) Survey Form - Page 1 I d, - -1 0 7 1A 9 0 0 <br /> California Integrated Waste Management Board -.. <br /> Part A- Survey BLUE OR BLACK INK PEN ..� <br /> TPID- C ) / Inspection Type (Fill one) <br /> Site Suffix: I J 1 s (� 45 �� / 1& Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �. + - - If Referral,choose referral type(Fill one) <br /> Identifier: i )�.,r�, ,A.) �,. N 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> /Ij <br /> Street <br /> Inspection Date <br /> City State ZIP Code <br /> � �" A �52y� I Time In Time Out _ <br /> Business Rep. Title F O AM m O AM <br /> f 'J , j". ; /_ �l�l PM O PM <br /> v /11-, - - - <br /> ____ <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 /> Tire Count(Whole/PT <br /> ®Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude j F] O 0 Closed 0 Altered <br /> If j__JJ 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck q <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> u_ -- <br /> Business Type (Fill all that apply) I- <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 S ? S�/✓r C, <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 1 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 00 114 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O <br /> 1 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 1 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 O In Compliance - No Violations <br /> O 0 Other: § — - - — -- <br /> Comments r <br /> r I � <br /> r�g� �r�'�/r i�".'� !� t�-�► E �/��i/(` -��j i <br /> Inspection Form Included: 0' <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � h I A _MIFF; L 13 j <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />