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Waste Tire ft. ' 'y & Inspection Repo Inspection Report Number <br /> State of California <br /> ®GBZs�& CIWMB 181(New 04/04) Survey Form - Page 1 a 5 - 1 0 2 5 6 9 3 <br /> California Integrated Waste Management Board - -- ---- -— --- ---- + <br /> Part A Survey BLUE OR BLACK INK PEN <br /> Inspection <br /> P <br /> TPID- ! L�� ? - I Inspection Type (Fill one) <br /> Site Suffix: Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local f If Referral,choose referral type(Fill one) <br /> Identifier: __ ((t't J �'t)/ '(fir/ t) t"i G', f 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 <br /> i Inspected By Inspector <br /> Physical Address'. <br /> _ . <br /> Street p [� l <br /> Ins ection Date 7 <br /> x <br /> Time In Time Out <br /> Crty State ZIP Code <br /> Business Rep Title --- [T 0 AM F�= <br /> r- ,1,, 0 AM <br /> t.(1 tYrt Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> 1� (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply): <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered 0Hauler O <br /> Indoor <br /> 0 Inactive 0 Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> 8 s„ esss'Type (F li all tha8 ripply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> (a Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection O 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 <br /> -- ----- ------- ------ 0 Notice Of Violation O 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 <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 0 / m / m <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tile Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 014 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/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 /> CommentsI <br /> - - - ' - �; L <br /> L,1J(1 1 �'1ia � i1,./Pt <br /> r' e <br /> l l( (i , 1 �� ) �P '� i <br /> rAi-1_ 1'j i�• � , t ('_It/ .�fJ��-, J✓ /E' i✓��`iri( 1 � _ VtPr;Jy�'� La� ;r� <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number inspector's signature Phone Number <br /> _.` 1. - <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X , ",/ °5' _� 1 I ; 62021 <br /> . <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />