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PW <br /> Inspection Report Number <br /> Waste Tire o%ey & Inspection ReState <br /> ClWM 181(New Survey Form - Page 1 ' - 0._ .. - - <br /> ,;,k CIWMB 181(New 04104) <br /> C a l ifornialnteg rated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Jag's z <br /> Business Profile ( , <br /> t&'1! m..�a..�.., ..., +v. <br /> Inspection Type (Fill one) <br /> TPID- <br /> 1 Site Suffix: I 1 lY ( �I Q Routine Q Re inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: Gy? �;A L�jA � I,tY' q V, � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> _ 1 — - - - <br /> Business or Facility N , <br /> -� InspectedBy Inspector <br /> bF�i <br /> Physical Address 7s E,�L- I I I Lull <br /> Street ^ r Inspection Date <br /> State ZIP Code I Time In Time Out <br /> City — _ O AM <br /> 1 [ — <br /> Business Rep Title � I ; 1 ��.�� PM 0 PM <br /> >r �� e� wI Operational Tire Type Business Role Storage Type <br /> jigijimilitFill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( y) <br /> (0 Active O Passenger Q Generator Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude �! Q Hauler a Indoor <br /> O Q Inactive - Q Truck <br /> Q End-Use Q Container <br /> Longitude - FTT I ] Q Planned Q OTR <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 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 _—.- 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 /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q 014 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <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 /> O Q Other: § _ t_ - - <br /> Comments 0 <br /> doral <br /> 1I ' /D C r CIY'1 Gltt F 4 UAL YtnIlrr �- <br /> C)n_o C _ ir t+ <br /> Inspection Form Included: <br /> Q ` <br /> Comments Included: Q' Inspector's Si nature Phone Number <br /> Business Rep's Signature Phone Number p g <br /> 6208'1 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X r l, i ���ai^' it � - <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> ■ <br />