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ection Re ort Number <br /> p p p _ p . <br /> Waste Tire ' y & Inspection Re ori <br /> G®®® Sta <br /> CIWMBB 181(New 04104)te California Survey Form - Page 1 _ - 11 0 1 9 0 <br /> California Integrated Waste Management Board <br /> Part A Survey BLUE OR BLACK INK PEN <br /> .: r, e dr f' t`' ,°, o-�,Ins__.peCYlOn Details <br /> fix r , . <br /> TPID- Inspection Type (Fill one) <br />} Site Suffix: . J `j `�) # Routine Q Re-inspection Q Referral Q Observation <br /> Local / r -- l If Referral,choose referral type(Fill one) <br /> Identifier: `' ; �•� '-fit I- I (' 1(/�tft v`, O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name j Inspected By Inspector <br /> I "1I I I <br /> (Physical Address � (./ � ��r'-r'' � �;1d•(Z ,,,� <br /> Street jf Inspection Date <br /> { < < Iri 1 �. <br /> (It i l -Vl1f� L '�-' ! - Time Out <br /> ---- State ZIP Code Time In 11 <br /> Business Rep Title AM = : �._I O AM <br /> l O PM O PM <br /> Lam_` �.t t Operational, til Status Tire Type Business Role Storage Type <br /> W pera <br /> rW (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply): <br /> (" ® Active Q Passenger Q Generator Q Outdoor <br /> PS LatiF1D Q Closed Q Altered <br /> Q Hauler Q IndoorG7_1 � Q Inactive Q Truck <br /> o <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> M r �rr�za <br /> Q New Tire Dealer Q Auto Repair (1) 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 MANIFESTREQUIREMENTS___-- — <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehiclei <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FTI / m / FT-1 <br /> Q O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q O 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/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities -_ <br /> Q O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> O O <br /> Other: § <br /> r _Wl �t f i.... w li ( 1''-f� 4- yl i `V i iL l i �e <br /> Comments- - ii ) ��jj� -( ! t r / a r 1 (;t <br /> f f�t•{ t ��k f <br /> C� `)�k -j-d <br /> CIr�lf k tl� i(l� �lE'it((.ly`: 4.!✓ .;! l r .t✓'ir/ tit n �� ; <br /> 1 <br /> � !••.t%/ <br /> I , <br /> 'Inspection Form Included: O' <br /> Comments Included: O - <br /> Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X /;, \/ 3= 1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />