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Waste Tire Su ;y & Inspection ReportInspection RJ'�epaort Number <br /> J� <br /> 6oia, Ct[WMate 181(New Survey Form - Pagel V 1 1 V Y <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- In <br /> spection+1 �� t' Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: r? I`1 L)Ci (fit YJ 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> � / Inspected By Inspector <br /> Physical Address J ! r V <br /> TY <br /> Street C,� C <br /> -- Inspection Date <br /> Time In <br /> City /' State ZIP Code TiTime Out" -_ <br /> Business Rep Title ( 0 AM O AM <br /> _ (( ®s PM :OE 0 PM <br /> OfOperational Status ire ype Business Role orage Type <br /> Tire Count (Who0j(Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> le/PT (� <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> GPS <br /> Latitude W �m o Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Q End-Use Q ContaLgitude — j'� iner0 PlannedQ <br /> OTR <br /> Business <br /> Q <br /> New Tire Dealer Q Auto Repair p Trucking Fleet Q Government ® 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 ® 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 <br /> 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 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 I 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 /> Lti f(✓i_� C :( ( �- %d'li i" I t/' (stJ� n U J <br /> I i f" jd C.{ ( f 1"1 ( ( �✓i' .�v Of f (-' <br /> T <br /> 'In spec ton Form InCIU. <br /> Comments Included: Q -- <br /> Business Rep's Signature Phone Number Inspectors Signature <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X E v A. "��i P 2 l <br /> White Copy:CIWMB Yellow Copy Oli(i,,lor Pink Copy:LEA <br />