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''j.- <br /> Waste Tire 18ioy & Inspection RepAkio' <br /> lnspection Report Number <br /> ���" Stale of California <br /> liliJa CIWMB181(New04/04) Surve Form - Pagel ! i 4 - 10 10 5 3 8 <br /> California Integrated Waste Management Board Y <br /> I(Part A-Survey BLUE OR BLACK INK_ PEN <br /> nspection Details <br /> TPID- J Inspection Type (Fill one) <br /> Site Suffix: I r' r L� {��I �L: L;) <br /> Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address / r .; <br /> 1 11 <br /> b, <br /> Inspection DateFO / h <br /> State ZIP Code <br /> I Time In // Time Out <br /> Business Rep Title Q AM 0 AM <br /> 1 0PM 0 P <br /> Operational Status F Tire Type Business Role Storage Type <br /> T <br /> Tire Count (Whole/P <br /> v (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> to Active Q Passenger Q Generator Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude m • Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude — Q Planned ` 0 OTR `"`"" "" Q End-Use Q Container <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet (a 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 <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 <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 /> Inspection Form Included: Q <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Inspector's Signature, Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � y,IP E I F2s 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />