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Inspection Report Number <br /> Waste Tire Su�ey & Inspection Repor*_ <br /> Ct1WMB 181(New 04/04)Sate of California Survey Form - Page 1 9 - 10 1 3 7 0 8 <br /> CIWM <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- ( _ �. / Inspection Type (Fill one) <br />} Site Suffix: I /""I ' ', J 1 L' I Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: f; (-M b' t( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J i' <br /> Inspected By Inspector <br /> Physical Address W - ' <br /> Sneer <br /> Inspection Date <br /> State ZIP Codi Time In Time Out <br /> Business Rep Title 3 AM 0 AM <br /> O PM m • O PM <br /> t v i Operational Status <br /> reType Business Role Storage Type <br /> Tire Count (Whole/PT (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m • ), Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Q New Tire Dealer Q Auto Repair Q 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 /> 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 (3) 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 / 7 <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: § NOW. <br /> Comments oollq t7�li" (ti I.trtCc-�,.r4 <br /> l t? Lr<: <br /> /!l 1�fy P 1. fe.1"t, r U'rt C fr/� c�, y <br /> �-( �('�.Ct fit(�' �' �� t("r't�6_' C t-r' ` -j !I'/ � ' 1 � r o ��l+. ("'t f) . �r 14 p <br />} 1_{ 1 1 __.:. /lvt/'i� t`tlil (.,� r.� �✓t' �``li.� .Yt� < � �f �f�' .�1 � re �i�r :i ) -t � �- - - <br /> 7- <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:10 Incorrect: XJ E X Mh A P I L 12 3 608'1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />