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I id <br /> Waste Tire Su&y & Inspection Repor Inspection Report Number <br /> 1 iiii ///��� ,( rt /� f4 <br /> r State of California ; 2 - ` ` ` j t 6 6 2 <br /> iigi CIWM6181(New04104) Survey Form - Page 1� I { 1f V V V L V. <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A- Surve <br /> 'T''q zl` yt^i' r,¢m, L+:r I, •, .a., '" t Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: i _R Routine Q Re-inspection Q Referral Q Observation <br /> 77 _- — <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: i� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — <br /> Inspected By Inspector <br /> Physical Address <br /> Street / / <br /> Inspection Date <br /> _ JE <br /> 1 Time In Time Out <br /> _ <br /> Business Rep Title State ZIP Code --�, _]O <br /> PM 0 AM <br /> PM <br /> Operation <br /> on_l Status$ *)tkr l� r" BuFilsin that ole (Fi®algthrae Tyapply) <br /> (Fill oneTire Count(Whole/PTE) l <br /> QACtIVe z✓rF 'ug Generator Q <br /> Outdoor: <br /> -- Hauler <br /> O Q Closed ,, 'AIt �ti1tr <br /> GPS Latitude — Q Q Indoor <br /> i,: ,�r�t�a ��r �"II t; <br /> Q Inactive !C d <br /> o Q Container <br /> Longitude — Q Plannedf% 1t ;O;✓('„ Q End-Use <br /> ;sS�att� l� II#llt1(ia 'l <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 /> y+ HAULING AND MANIFEST REQUIREMENTS -1 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 @ 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q (Required for NOV or EXT) <br /> 14 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 i CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-yanifest 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: <br /> Q'Business Rep's Signature Phone Number inspector's Signature,— Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E <br /> 1,12131 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> ■ <br />