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.n. <br /> - ZI3 <br /> Waste Tire S sy & Inspection Repor Inspection Report Number <br /> II State of California <br /> CIWMB181 <br /> Waste <br /> eManag) Survey Form - Page 1 1 7 - 1 01060 7 <br /> California Integrated Waste Management board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: rr r� El <br /> 1 ® Routine 0 Re-inspection Q Referral Q Observation <br /> I ol <br /> Local �'Y If Referral,choose referral type(Fill one) <br /> Identifier: /'A t K 0 CHP Q CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name ( �_ Inspected By Inspector <br /> Physical Address <br /> `-C I <br /> Street <br /> r ^, Inspection Date <br /> FT61 t/ <br /> State ZIP Code <br /> I Time In Time Out <br /> Business Rep Title �� AM 0 AM <br /> 0 PM 0 PM <br /> ! tCt_l :,1 X111 (jyfl I <br /> Operational Statusire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) % (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �"y I I 177ole Active O Passenger 0 Generator 0 Outdoor <br /> I O O Closed 0 Altered <br /> GPS Latitude m • Q Hauler 0 Indoor <br /> _ O 0 Inactive 0 Truck <br /> Longitude — O Planned O OTR End-Use Container <br /> Business <br /> Q New Tire Dealer ® Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder O 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 <br /> O Notice Of Violation O Extension <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred I CIWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> 10 Q Other: <br /> Commentsklfl�t�(t^ /2C <br /> JJf /lY ' r ,( <br /> — — <br /> �7L= ili�i<<)t^d 1�, �-�� ��vt�f�yl r�+ (��, � '�t c rc.� /c' rr p>�y�t.. . A/c) <br /> - - <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ,YI <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � �' � �. p I LIELIEJ 11 2 3' (52081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />