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- Waste Tire f -Vey & InF <br /> ��:j`"7 State of California <br /> pection Rep Inspection Report Number <br /> ;:44- i CIWMB 181(New 04/04) r--rve i- -4 A r <br /> California Integrated Waste Management Board Y F rm. - Page 1 I 0 14 Z) <br /> Part - Survey <br /> Business <br /> BLUE OR BLACK INK PEN <br /> ss Profile Inspection Details <br /> TPID- i <br /> Site Suffix: I 1 y _ Inspection Type (Fill one) <br /> l l �� Routine Q Re-inspection p Q Referral Q Observation <br /> Local <br /> Identifier: If Referral,choose referral type(Fill one) <br /> Business or Facility Name Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Inspected By Inspector <br /> ` �e r v fc L <br /> Physical A re�ss <br /> Inspection Date f Q 1 / v <br /> Business Rep <br /> Time In Time Out <br /> Title / ® AM / y@11 AM <br /> 1�U 7�50 f 0 PM / Z O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 20 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f , <br /> 9 Active ® Passenger ® Generator 0 Outdoor <br /> GPS Latitude O Q Closed Q Altered <br /> • Q Hauler Q Indoor <br /> Longitude _ <br /> O Q Inactive ®Truck <br /> Q Planned Q OTR Q End-Use Q Container <br /> Business Type Fill all that apply) <br /> Q New Tire Dea er a air Q Trucking Fleet Q Government <br /> Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dea er Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Static Q Hauler Q Agriculture Q Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS --I <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§.12951 -Waste Tire Hauler Registration and Transport of Tires — Q Notice Of Violation Q Extension <br /> Q Q PRC§ 2953-Contracts with Registered Waste Tire Haulers, <br /> Compliance Deadline <br /> Q Q PRC§=2956-Registration/Decal in Vehicle <br /> Q Q 14 CCP, ; 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 14 CCP, 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 IQ 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 /> ------------------------------- – ---- <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> CA%Y <br /> �rJIG�l v�1 l► \/�`�� r V�O�A�J cit' f eMtio l 0 <br /> ° Co e►�13 a C— art-�j ��Dl�c t1 1/l <br /> Inspection Form Included: O93 <br /> ^ <br /> Comments Included: Q <br /> Business Rep's Sig ature Phone Number In p g_atureJ Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: t 62081 <br /> 127 . <br /> While Copy CIWMB Yellow Copy:Operator Pink Copy:LEA 1` <br />