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�!J Waste Tire S40y & Inspection Repo Inspection Report Number ■ <br /> ss <br /> Hgo State California Survey Form - Page 1 <br /> CIWMBB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Spe.1G,11d1'Fte1 u p,��' o " <br /> TPID- f, � <br /> EY <br /> Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L' <br /> Inspected By Inspector <br /> �_ ------------ - <br /> Physical Address I C <br /> Street <br /> � Inspection Date <br /> I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> fi , � � • �0PM 0 P <br /> ,. , <br /> Operational Status 9 "7 Business Role �� 7 <br /> r a. -' T a <br /> (Fill one only) allp (ys (Fill all that apply) � t,�� . <br /> Tire Count(Whole/PTEA r" a rat I + ll yore rr <br /> 7 : ® Active r � I w ® Generator <br /> "j arta arty v"I <br /> Q Closed <br /> Latitude heti r a <br /> GPS raS"�aY�7�rtaSaa i Q Hauler <br /> Q �yt I���C�f���zcat aa7ayYra� <br /> Inactive 4" ti�h��t ' " aa�al r� c��tws>i <br /> O <br /> Longitude 0 Planned ^ � �� � w Q End-Use <br /> " <br /> ���l/ <br /> ,« � 'u 7'� �h�t�h,�, 7� at �t•'y��� id a�s�.F�raG +� C r �,t�,;t1+"'a a5�; w ,� rA+t`�z°,r � c M"> a a� <br /> New Tire Dealer & Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body (1) 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 /> U I A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q 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 <br /> -Tire Program ID Number from CIWMB Q m m <br /> Q Q 14 CCR§18459.1 (a)(b)(c) (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q I Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 1 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: - <br /> Comments ' <br /> Inspection Form Included: Q' <br /> Comments Included: Q _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:` Incorrect: X tl . <bo I_ I <br /> ■ - - <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />