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Waste Tire Su ;y & Inspection Report inspection Report Number <br /> StateB 81(Neis I Survey Form - Page 1 - � Q 1 3...4 <br /> .CIWMB 181 New 04/04 <br /> California Integrated Waste Management Board .—_ _ <br /> Part A- Su a BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> (., <br /> Site Suffix: I :� `,' / 0 Routine 0 Re-Inspection 0 Referral 0 Observation <br /> Local ✓ t If Referral,choose referral type(Fill one) <br /> Identifier: �a �+ � fit., '� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 1'I IrG�t` 0LI�� Gc >fiy�` _ 1_ � <br /> Physical Address -� ' -/ 1 I �';6'•. it d <br /> Street <br /> I i .. 1 Inspection Date <br /> G) <br /> >f k fioi , ( ,;, � , v <br /> State ZlR Code Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> MOPM m ' L�I 0PM <br /> Operational Status Tire Type Business Role Wtorage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PT <br /> ®Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> 0 New Tire Dealer 0 Auto Repair (P Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> e <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 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 (D- PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> o 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> T / 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 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/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 <br /> j <br /> 21Jrutk� C10 TUI x,►11IL f ILK) t�iLti�'i'�.( 7 U'iC1 >IA)o- it lw <br /> 15 ✓p uoc �,� k.' , 5✓6ce� btu-1 'ur�VtJ�a � � i ( ice( I dc L, f(I �04 <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature o__ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:� Incorrect: X Ak \/ I��q 141 p i L I 12 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> -- ' - <br />