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spection Report Number <br /> W ste Tire S & Inspection Repo_. <br /> ■ 6�. .. ( 1 2I n <br /> Si Stat ofCalifornia p f j j f l 1 <br /> -_ . CIW B181{New04104) Survey Form - Page 1 BL { _i— �i L. ��11 1! VV. - <br /> pIiZID <br /> California Integr ed Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A- Surve <br /> Inspection Details <br /> TPIp-; Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection Q Referral Q Observation <br /> If Referral,choose referral type(Fill one) <br /> iii-ocal <br /> .Identifier: OCHP 0CIWMB Q Complaint Q Educational Visit Q Other I <br /> _ - <br /> Business or Facility Name Inspected By Inspector <br /> -�� <br /> Phy ical Address✓� - i <br /> Street Inspection Date <br /> �—= State z/H Code Time In Time Out <br /> City � AM FF0 AM <br /> Business Rep Title O PM , PM <br /> - <br /> -- - __ Operational Status Tire Type Business Role Storage+Type <br /> II <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fi'I all that apply) <br /> Ti e Ccuunt (WhoIelf PTE <br /> � Q Active QPassenger QGenerator Q Outdoor <br /> l Q Closed Q Altered <br /> GpS Latitude , I I Q Hauler Q Indoor <br /> 111 0 Inactive Q Truck <br /> _ —1 O Q End-Use Q Container <br /> Longitude - � I Q Planned Q OTR <br /> Business Type (Fill all that apply)" <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 /> V A HAULING AND MANIFEST REQUIREMENTS ---._ Q Notice Of Violation Q Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m <br /> Q 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> . 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 O 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 O Referred/CIWMB Enforcement <br /> Q 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 Q in Compliance - No Violations <br /> Q 0 Other: § --- - - - -- <br /> Comments _ <br /> Inspection Form Included: 0' <br /> Comments Included: 0 Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: x V ' •�y� p���_ _'__I Z <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA © ■ <br />