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Waste Tire Su- ,y & Inspection Report Inspection Report Number <br /> Stateoornia Survey Form - Page 1 I -_3 - i - _ _3 2 <br /> CIWMB 181 181(New 04104) <br /> California Integrated Waste Management Board _ <br /> Pant A- Survey BLUE OR BLACK INK PEN <br /> nspection Details <br /> TPID- ! i7 /� n ( - Inspection Type (Fill one) <br /> Site Suffix: I 'c J `, VJ ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -i ., { t• 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> LBusiness or Facility Name % <br /> _. Inspected By Inspector <br /> Physical Address <br /> J ErnY ( L lYrE-' - <br /> 1� L Inspection Date <br /> State ZIP Code Time In Time Out <br /> Business Rep r Title Q AM m : m Q AM <br /> QPM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholelPr� <br /> 0 ( SysFill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> TE'" <br /> Active 0 Passenger Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude m • 0 Hauler 0 indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - D Planned 0 OTR 0 End-Use 0 Container <br /> ata ply) <br /> 0 New Tire Dealer 0 Auto Repair #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 /> VV A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 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 <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/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 1 0 1 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 /> - - w-fikif (Yi l iL,- _ f t + " ..{ E` - V, <br /> r'd, <br /> — —{ — --R-- - — -- - - - - — — - <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's$ignatur <br /> X\ �. Phone Number <br /> - -- -- <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 1 A, rp P I L I El 11 2 i 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />