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Waste Tire Suy & Inspection Report Inspection Report Number <br /> State of California <br /> `aID CIWMB181 <br /> Waste <br /> eManag) Survey Form - Page 1Lt_2___-_ 0 0- 5 3 5 <br /> California Integrated Waste Management Board _ _- _ -_ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) _ <br /> Site Suffix: f III Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> _._ __.._ _, r J _ [ LLIPhysical Address <br /> 0 -- <br /> Street _ <br /> Inspection Date <br /> City / State ZIP Code Time In Time Out <br /> Business Rep Title @AM 0 AM <br /> J - 0 PM 0 PM <br /> v, k/",/ \J . <br /> Operational Status Biu' Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) <br /> 7.i <br /> 0 Active k1f Q Generator 0 Outdoor c <br /> uw�S�,7 <br /> -Latitude <br /> D 0 Closed r <br /> GPS f �a� 0 Hauler 0 Indoor <br /> 0Inactive 0 g ' " <br /> p <br /> Longitude — ! 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 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 t 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 Other: § <br /> Comments <br /> �-._�.. - __ _ t Y-r� t �-� r - ti ��.'� V- !1•"' lar ,_Pf <br /> r � v <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number _Inspector's Signature L Phone Number <br /> _ � +� _. <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ;.r°. :,,,,�' 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />