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ffiWaste Ti r U Ins ection Report Number <br /> � y & Inspection R rt� p � �State of California 1 r j t ) i i <br /> CIWMB 181 NL 04/04) Survey Form Page 1 4 ,j Lr f V <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A St ii <br /> " �,/ �a'aw •" ,ne �' 0 45„ Miu •u _� 5 "ya,�k 13�>ria A F r f <br /> A, b ti.a <br /> TPID Inspection Type (Fill one) <br /> Site Suffix: Q Routine 0 Re-inspection Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> (i <br /> Physical AddressIf,f�l Vo- <br /> E't Inspection Date �J I �� L3 C1 T— <br /> State zip Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> ---L_._ O PM _ 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> " D Closed 0 Altered <br /> GPS Latitude EU_ ,�� Hauler 0 Indoor <br /> II _ ____1D Q Inactive 0 Truck <br /> Longitude — � � � � I 0 Planned 0 OTR <br /> 0 End-Use 0 Container <br /> p 1 <br /> Business Type Fill all that a <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 AtAto 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 Q Extension <br /> 0 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 T1 <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / m / <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 1 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 I 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 0 Other: -- <br /> Comments a 1 <br /> .•L.t - �,L p°"•:'l.l�.r�l- c- �`�7^�`"�.��°i of`.k- -- — - o l! <br /> b � -� - ---v'P �•cry-�`. � c; �-- - -- '- _j,..1. I-__.-.��-tea.`. --_ _ <br /> } <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: _ ��rL�'l� 1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />