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_L..t-. <br /> _ <br /> Waste Tire Su_ .y & Inspection Reportlnspectio ReportNumber <br /> State of California <br /> CIWMB 181( e ) Survey Form - Page 1 I - ..3- 0 9 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> - Ispection Details <br /> TPID- Ld <br /> �� Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection Q Referral Q Observation <br /> LocalLc <br /> � / If Referral,choose referral type(Fill one) <br /> Identifier: ' J ' '�'t` CC ty t 0!�,t fit. {1 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> j ( Y- Inspector <br /> p <br /> Inspected B <br /> L _ J <br /> LC L') <br /> Cif ' <br /> Physical Address <br /> `; <br /> Street Inspection Date ( ':l ) r <br /> �1' j ( <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM L 0 PM <br /> Operational Status Tire Type Business Role PStorage Type <br /> Tire Count (Whole/PTE: (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger (:)Generator Q Outdoor <br /> GP$ Latitude <br /> O Q Closed Q Altered <br /> � . <br /> Q Hauler Q Indoor <br /> �Planned <br /> Q Truck <br /> Longitude - Q OTR Q End-Use Q Container <br /> Q New Tire Dealer (D 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 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 /> M / M / m <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: § J <br /> Comments P t 1 t �f ✓I ` f r.. ( 0 )i�t.t ^l o 1 �' `r l.f i I <br /> � IU c I u�. .Ir _ <br /> t(.; � � ✓tt',(,. t Y'•. '.f u<.`;.; i '�,; lT�' t (G; ;r t//'r .I CfYE..'t'�• l vtr�; '; L�.-( /'�i�k_'�ri%t t�('� <br /> A n d Ai S C t.4 `1S-,PdNC 1 t"'1li r >I C�vt�t{ F f 1""l lr�ll�r5 �j r t,Prtt�✓S <br /> ! T✓i,i�j) , 1 h ` '�( ( fGr iU ! '.� � uvi It[-, ^ 'i -,,t /J1/4 <br /> Inspection Form IncIu a ': <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Sigpature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 62081 <br /> f+. o+,lp L 1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />