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ction Waste Tire Su&* Inspection Report• Ir <br /> R <br /> State California Survey Form - Page 1 1 V ti,/ 4 �,! 7 �,/� <br /> / <br /> CIWMBB 181(New 04/04) <br /> California Integrated Waste Management Board aJ�ReportANumber <br /> ort <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- Inspection Type (Fill one) <br /> Site Suffix: I I I � �, l� ) 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ,1 If Referral,choose referral type(Fill one) <br /> Identifier: i �(l Lt ; 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> t <br /> Physical Address <br /> s <br /> ri <br /> Street <br /> Inspection Date <br /> -- — Time In Time Out <br /> State ZIP Codi _ <br /> Business Rep Title OAM O AM <br /> [T]0 PM FE : L OPnn <br /> Operational Status ire 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 /> t-" Active 0 Passenger 0 Generator 0 Outdoor <br /> m <br /> GPS Latitude 0 0 Closed 0 Altered <br /> 0 Hauler 0 Indoor <br /> U 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR End-Use Container <br /> �s" <br /> 0 New Tire Dealer 0 Auto Repair IS 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 <br /> 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 <br /> 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 i 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 /!�V ) j <br /> .A V1 c (fa�'- r%Ii%1( J6 �C:t 1"� ISE' ( t i� ' ✓✓,< <br /> I"; h c;i Gr �r '`if ii X-i. 1+``�';(f �I✓� ' (jr: t �r :.i�( a Vit : 1 c�� t)I/E l s{ 11 <br /> � <br /> j <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Si nat_ur_ Phone Numb- <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �, \/ X 14 62081 <br /> F L t 3 <br /> White Copy:CIWMB Yellow Copy,Operator Pink Copy:LEA <br />