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Waste Tire* & Inspection Re °t Inspection Report Number <br /> State of California y Y 1� _. - ■ <br /> � t Survey Form - Page 1 i 5 - 1 0 1 4 8 0 4 <br /> CIWMB 181 New 04/04 <br /> California Integrated Waste Management Board <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> tl bless '� i (r�nz'N _ Iy,� w �r c h,�z i�'F V��tsr;Idtti''axtf,'r: iiHm „.r rMr�r . <br /> IM1 � Elm,.+ 1�,•k.�"i.:;N.O'�ri1A Pw': i uji+?:'�� iz +°_ a" ?kwtFiui� <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: <br /> <<?G c, I %\ -Q cn. �`� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> _.. <br /> Business or Facility Name �— Inspected By Inspector <br /> -- <br /> Inspected <br /> Physical Address <br /> r C 11 V.J VIA <br /> (l 1 <br /> Street <br /> i <br /> ��(( \\ i `\ Inspection Date E) t:., <br /> City State ZIP Code Time In Time Out <br /> Business RepTitle 0 AM <br /> L 1 Q AM <br /> O PM L�� ' O PM <br /> C ) ' ilonal Status (ie eBusiness Storage <br /> Type <br /> ((Fill one only) Tire <br /> apply) (Fill all that apply) ( lall that apply) <br /> y)outWi P <br /> Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude ��� Q Hauler Q Indoor <br /> �J Q Inactive` Q Truck <br /> Longitude — Q Planned Q OTRQ End-Use Q Container <br /> Business Type (Fill all that apply) _ <br /> _,r...`�u a�i <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 (j) Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> f <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> --- <br /> I. Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension, <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 /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <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-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q In Compliance - No Violations <br /> Q Q Other: § --_-- <br /> Comments <br /> `, ' <br /> _f i (�. (• l'-y�r'=, may` ! ,// i� iri�.t ��i�,�"C '�� "���� — - _. - - <br /> y/, <br /> Inspection form Included: Q' <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 62081� � i.,,; ;<;y�+, rv�, ""� �_ � n � � d� i <br /> ■ op <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />