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=- y & Inspection Report Inspection Report NumberWaste Tire Su <br /> �iaw33• State of California <br /> CIWMB 181( e ) Survey Form - Page 1 ( - 1 0 1 4 8 0 1 <br /> California Integrated WasttManage <br /> Waste Management Board ___ _ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> .,e.4,"de�_,Ikl. <br /> TPID- - Inspection Type (Fill one) <br /> Site Suffix: I l l i-� I I F > ) ! ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local. If Referral,choose referral type(Fill one) <br /> Identifier: f <br /> O CHP 0 CIWMB Complaint Educational Visit Other <br /> Business or Facility Name - -- <br /> Inspected By Inspector <br /> Physical Address <br /> - <br /> Sffe'et <br /> Inspection Date <br /> Cit State ZIP Code Time In Time Out_ <br /> Business Rep Title QAM _ 0 AM <br /> EE ' LHOPM � � 0 P <br /> J1 <br /> Operational Status Business Role Storage Type <br /> ^rr (Fill one only) ( ( 1 (Fill all that apply) (Fill all that apply)' <br /> Active Di ® Generator 0 Outdoor <br /> Latitude O 0 Closed <br /> GPS 0 Hauler 0 Indoor <br /> 0 Inactive (J tuck <br /> Longitude - 0 Planned D OTR 0 End-Use 0 Container <br /> „.rte. <br /> 0 New Tire Dealer 0 Auto Repair 0 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 ®Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _VA HAULING AND i�ANIFEST REQUIREMENTS <br /> 0 _ - - - - --- -- - - 0 Notice Of Violation 0 Extension <br /> 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 III EE / III <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 1 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 /> CommentsAl-(� <br /> r'>� >c.Ci7Z� 1:^EVS <br /> ------ <br /> 4f. <br /> Inspection Form Included: 0' <br /> Comments Included: 0 _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> a 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X :, , - lr L I t <br /> ■ White Copy:CIWMB Yellow Copy:Operator FV `Pink Copy:LEA ® ■ <br />