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Waste Tire S '& Inspection Repornspection Report Number <br /> "Y. ..rr State of California — ......... .._..,... .-._...._ --._._ <br /> CIWMB 181(New 04/04) Survey Form - Page 1 - <br /> 9 1 u 1 313 <br /> 1 - <br /> California Integrated Waste Management Board <br /> Part A-ipSurvey BLUE OR BLACK INK PEN_! b Inspection Details <br /> a w, <br /> TPID- Inspection Type (Fill one) <br /> Site Sufftx; t �( I �/ I - L� 0 Routine Re-inspection 0 Referral 0 Observation <br /> Local i, LLL If Referral,choose referral type(Fill one) <br /> Identifier: , •A -r C t , ' I'"Lf 't:' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Ne - - <br /> # Inspected By Inspector <br /> In <br /> Physical Address —__� .� J �✓ I i..P5 <br /> -h Kes <br /> { <br /> Street � 1 <br /> L f�� 1 ! It �� J� ! Inspection Date � (�,(� / f IJ / =oc- <br /> city <br /> �— State Time In Time Out <br /> Business Rep Title <br /> Q AM Q AM <br /> 0 PM 0 PM <br /> ry) 0Nd 0 vi e"r V <br /> Operational Status Tire Type Business Role Storage Type <br /> Tlwe fount �" =�2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �� <br /> ®Active 0,Passenger; 0 Generator 0 Outdoor <br /> � 0 Closed 0Altered <br /> GPS Latitude . ��—� 0 Hauler 0 Indoor <br /> 1 <br /> - — 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR End-Use Container <br /> Business Type (Fill all thatapply <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 4 <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 t <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <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 <br /> 0 I 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 f ` 1/ t`0(:..I�It�rt �G r G� . ��tf ) r() 1_'j <br /> Jtr';, 1 Y!L �2 G 1< F 4{ �/; <br /> b w jo �( I, � ' J(1 <;f <br /> iA )e( 11'C'jl, Q Pi"f)✓Gt,e, <br /> 110H n;�: � rl� ,,;�.-,, t - �� �� );, .�-� �fr ' �. ( �;-��; r'ar�7< )�;,�,� �f 1 I, I•,, l � , . .t.. <br /> Inspection Form Included: 0: - <br /> Comments Included: <br /> DI Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> I � _ _ <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X 62081 <br /> ;�, ,+f, -' I_ . <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br />