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Waste Tire Suay & Inspection Repor ,Inspection Report Number . <br /> ®®$ State of California ' <br /> CIWMB' 181 <br /> 1t1 V V V Y <br /> California IntegratedWase Management Board Sy Form Pg1 ( <br /> Part A Survey BLUE OR BLACK INK PEN <br /> tNofile Inspection Deta <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: , Routine Q Re-inspection Q Referral Q Observation <br /> Local r ~4 If Referral,choose referral type(Fill one) <br /> Identifier: --- t'� i; ��,t j,• t.; Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name i ! <br /> 1 Inspected By Inspector <br /> `�� � I I ✓ 1 �� r <br /> Physical Address <br /> V? <br /> Street <br /> F- <br /> �� Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> r " O PM PM <br /> ' 4�' !''� !) tf( Operational EDEE-1e1E : E_L <br /> - O <br /> p rational Status " � ! °if'r" Business Role Storage Type <br /> (Fill one only) (FI1, 1 ( `° (Fill all that apply) (Fill all that apply)', <br /> The Caunt�(V4Iho el[�TE)11 mw + <br /> QActive (� � (a Generator Q Outdoor <br /> 0 <br /> Q Closed �rj (; <br /> Latitude :� �. <br /> GPS `�� 1ti�a t i1a, Q Hauler Q Indoor <br /> E El -- - - Q Inactive <br /> Longitude Q Planned Q OTR Q End Use Q Container <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 <br /> 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 FTI mM <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 § P 9 Y <br /> 14 CCR 18459.3-Retention of Manifest Forms and Tire Tri Logs for 3 ears <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred t 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 0 In Compliance - No Violations <br /> Q Q Other: § <br /> sl <br /> Commentt +(>r-�_ IJt i � ((-)i`I t e,r�.? _ L��t� �' � + (•"t!! _ty+!i l�?(.i i t>'_t� 1 ,T(. 'i .�r {,..{ ` Cf `E�f <br /> C t ^ <br /> 1!�u!, �;•1�. e ( ;( ,(�� � V`�u��(�t •� {1 t,ti1� �� !t< � ���ti,{i(4' ��{ �"t � ) ?�';'1i✓ y�"'(,i ,V' f( j. ;ty <br /> VIC <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature- Phone Number Inspector's SignaturePhone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X E, :M;�,A, M ;" a� 1 I 31 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />