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s Ins ection Report Number <br /> ■ Waste Tire Su`_ y &'Inspection Report p p <br /> •°' State of California <br /> Survey Form - Page 1 2 0 13 7 7 8 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board -.. -... <br /> Part A Survey BLUE OR BLACK INK PEN <br /> µaOa„`�,r.x ( etQ'IS T ✓r Y � 4 a;? .r"",✓,r «u,ry�w tom, <br /> TPID- iInspection Type (Fill one) <br /> I Site Suffix: I ( -� ELI l Routine Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: J r� ` t �, ; 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> ', _ <br /> Business or Facility Name } { Inspected By Inspector <br /> I _ <br /> Physical ddress ) _ t.' LI 1 <br /> Street <br /> Inspection Date <br /> / <br /> City ��---��— f State ZIP Code 1 Time In Time Out <br /> Business Rep ` t. i Title Q AM Q AM <br /> ' t' � • �_ QPM ' � QPM <br /> Operational Status TireType Business Role Storage Type <br /> (Fill one only) (Fill all that apl (Fill all that apply) (Fill all that apply) <br /> ,Tire Count(Whole/PTE) , :01 <br /> " y Q Active Q Passenger Q Generator Q Outdoor <br /> O 0 Closed 0 Altered` <br /> GPS Latitude m • 0 Hauler 0 indoor <br /> -T Q 0 Inactive 0 Truck <br /> ---(� <br /> Longitude - r I E 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill alt that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer Q 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 <br /> -- -- — - -- ----- --- - 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 /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m m <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 <br /> (� In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments ' '1 r <br /> )(-,vdcc( E'1(_. <br /> e <br /> 1161 j {C;�( i'i_ �1�� ;r yl; of r (/ Cit i"1 t ✓` ✓_Gi �Gr `_, <br /> 1 �)r?I� r" e T,fi !f irk � (' �^ �J (..( r ,;ry. .'+ � rl 1''✓r^, �� '� l i,(' f 4 <br /> Inspection Form Included: 0J <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X ,a ;'�, ( L . �, 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA EWA <br /> � S <br /> I� <br />