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■ Waste Tire Su y & Inspection Repor Inspection Report Number <br /> ■ <br /> State of California ' <br /> '- CIWMB 181(New nage) Survey Form - Page 1 1 1 - 1 v 1 3 Z 2 4 <br /> California Integrated Waste Management Board Y g <br /> Part A Survey BLUE OR BLACK INK PEN <br /> Y"e i N�__-?"� ,Yy i <br /> _ .�' t➢ a�„M `r �z✓' f�,y't'aa; +�""a <br /> + �yu�� 15, f,��t"�; � <br /> Site - r -_ Q Inspection Type (Fill one) <br />} Site Suffix:TPIRoutine 0 Re-inspection 0 Referral 0 Observation <br /> If Referral,choose referral type(Fill one) <br /> Local <br /> Identifier -- e <br /> � � f <br /> �i(�1 a-i_ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - <br /> ;- _ Inspected By Inspector <br /> Physical Address <br /> Street <br /> _ Inspection Date <br /> City l State ZIP Code Time In Time Out <br /> Business Rep Title 7 <br /> Q AM � Q AM <br /> [T <br /> QPM QPM <br /> '— <br /> Operational Status Tire Type Business Role <br /> Stonag <br /> y (Fill one only) (Fill all that apply) (Fill all that apply) (Fill <br /> ,y <br /> ®Active 0 Passenger 0 Generator 0 Odip <br /> ��Wn"N <br /> 'g„ "�f <br /> EEI -�� <br /> D 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 in 6 + <br /> r D 0 Inactive 0 Trucic �pmxF`u <br /> Longitude - I 0 Planned 0 OT( 0 End-Use 0 Container <br /> Business Type (Fill all 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 0 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 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 III / m IE <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <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/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 0 In Compliance - No Violations <br /> 0 I 0 Other: § <br /> Comments / q <br /> , '. _�r'�{�C. ._ Llii .,�Yt_�.__ / �� tr`lt�. t(ll/ Sl, �y:.f4 <br /> `�',^rl',! :�ll '' f;� �?IJ rff J f 1,k 1 tk- <br />} - - _y <br /> --_- �ti z ,K.i�`Pry " 7'* r 'l °+� "lFr^r 'wrr'':rlu 2,.;.,x+ r z�>"a' i,y✓V ✓ �, r./rry v d ,3i;,(m l"1'May/✓'„ ✓M7 r; ^jz` n;< F ,GX+" <br /> Inspectiotl Form InClUded. �i s d ,/✓ s/ a` / a r // r"fir yal ✓ p �h� ✓,�"f '"✓ °G"✓am' �r �✓r at "r Mwa4q r, l" a"r �r";a i "` X,{✓ n <br /> s, .X ,.r ,„ , e /,. �-�� w " � �4 r.,r ✓�n M„t. a �4- i,,✓.��" r iI4� ,�� ✓ t i, �4 rr,i�' J', <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X t. 62081 <br /> 0 a , or/ I_ <br /> ■ - -_ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />