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t <br /> section Report Number <br /> Waste Tire Su & Inspection Repor -' p -_ p _ - <br /> 8"T7 State of California i _ /�''�] �Jj A <br /> Califon intCew 04104 <br /> IWM d181(Ne Management Board Survey Form - Page 1 �/ 1 �+ �i 3 4 � 3 ''. <br /> - BLUE OR BLACK INK PEN <br /> Part A Survey Ins <br /> etC � f,wt — - - <br /> Business Profile. p - ,r�►C '40"t",_ �, �x�...: --- --- -- <br /> I <br /> TPID- C �._ _j I Inspection Type (Fill one) <br /> Site Suffix: - 0 Routine 0 Re-inspection (D Referral 0 Observation <br /> LocalD� / If Referral,choose referral type(Fill one) <br /> Identifier: j (�` Gl I k� �,.0 ?'t 0. 0 CHP 0 CIWMB 0 Complaint (D)Educational Visit 0 Other <br /> Business or Facility Name (J `j Inspected By Inspector <br /> lq <br /> �_._- ', .• 1, l _,r ri r! i _ L I <br /> Physical Address ,� �--- <br /> Ij a <br /> Street Inspection Date <br /> A <br /> StaPe ZIP Code Time In Time Out <br /> Business Rep Title -, } AM`y. O AM <br /> .. R (QPM � O PM <br /> Operational Status Tire Type �� Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> Tire Cqunt(lVltole/'TE)" Nk, <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 <br /> GPS Latitude , Altered 0 Hauler 0 Indoor <br /> D 0 Inactive D Truck <br /> Longitude — FTTT <br /> FT_T_FF� Q Planned 0OTR End-Use Container <br /> Business`type (Fill alk thatapply) _ <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel i <br /> 0 Used Tire Dealer0 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 _____ _ ___ 0 Notice Of Violation 0 Extension <br /> Q 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 <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> 0 0 <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 & 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O <br /> 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 (Other: § <br /> Comments <br /> Cpi <br /> } 1 hj 1 <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> ,.Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> . _ 62081 <br /> INSTRUCTIONS ON BACK Correct:® incorrect: X i4 fr�� r' I " ^_ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br /> ■ <br />