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Inspection Report Number <br /> Waste <br /> aste Tire SuWy & Inspection Repor- <br /> State of California <br /> IWMB 181 e -wZSurvey Form Page <br /> California Integrated Waste Management Board 6 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Ir1s ection Details <br /> 74 - <br /> SS <br /> 'We P . <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix , 5 0. 3 <br /> Lq� LO-Ltj Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ..7 C�nC7CXG �GUYI l� j Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> --1 <br /> Physical Address � 3 — 5 ���-1- ,�� � t�Cr <br /> Scree P <br /> Ins ection Date <br /> I� _� ► C)_'�_�_._ <br /> City State, _ltat_q__,L Time In _ Time Out <br /> R t;n �; <br /> Business Rep Title 0 AM O AM <br /> 0 PM 0 PM <br /> _._ VS..I ! . ..fes r _._,_:_.._._I C_�`t4_ _ _ _�I - - - ___ <br /> s, Operational Status Tire Type <br /> �t.l)_ Business Role Storage Type <br /> `> ± <br /> 11 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that appy, <br /> "mall o ® Active Q Passenger Q Generator Q Outdoor <br /> --y0 <br /> GPS Latitude <br /> f q Q Closed Q Altered Q Hauler Q Indoor <br /> _ _._ <br /> _ � Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 ® 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 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FFI / FTI / M <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators r In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> dcS:-Ca` <br /> Inspection Form Included: Q <br /> Comments Included: Q - - --- <br /> Business Rep's Signature Phone Number Inspector's SignatureA: Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �;,��a ,a� I_ Y . <br /> s■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />