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Inspection Report Number .Waste Tire SLA6y & Inspection Repor <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 k 4 - 10 1 0 6 45 <br /> California Integrated Waste Management Board ---- -- --- --- - - <br /> Part A- Sur BLUE OR BLACK INK PEN <br /> t." Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> � J T&I - v <br /> Site Suffix: 7�1 .� ✓ 7i (a)>Routine Q Re-inspection Q Referral Q Observation <br /> Local '�� If Referral,choose referral type(Fill one) <br /> Identifier: yt DCA qv�i i C-D t't_•� ' t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B Inspector <br /> v P Y P <br /> Physical Address I O <br /> VJ <br /> Street <br /> Inspection Date [0::a b tJ <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title AM O AM <br /> PM 0 PM <br /> r ry 1POV`Lff, blit 61 ti <br /> Operational Status Her A' Business Role <br /> (Fill one only) �( C) t"'� (Fill all that apply) � I II) M1llaf <br /> k' <br /> IS Active a�f �" •� Generator <br /> r <br /> °�Q Closed C � ,h <br /> GPS Latitude � Hauler <br /> D Q Inactive <br /> PlLongitude - End-Use Giqr"r;( °�� i�,'✓�„„ ��,tM+���I', <br /> �`"' i✓Y"P� H rr�tiPB",,r'�"' i <br /> anned <br /> Q New Tire Dealer Q Auto Repair ® 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 /> -- ---- ----,_ __1 <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 11 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline fr <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / 17 / 7 <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 1 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O - - - <br /> 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 /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q In Compliance No Violations <br /> Q Q Other: § <br /> Commentse'tit f f Ic l� ('C. cyl'j yLC ;_ P 1C> LCJ((s1r cd, <br /> kfoi-e( 1 G. t_C4.fl <br /> - <br /> (() 7'X 0 (1 !c1 ( ?l r1 o tic:•1 - <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 ?, 04 R�C �� � l 2 � 62081 <br /> ' White Copy:CIWMB Yellow Copy:Operator Pink Copy`LEA ® ■ <br />