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Waste Tire Suy & inspection Reporspection Report Number - - - � State of California , Emil CIWM6181(New 04/04) Survey Form - Page 1 10 c California Integrated Waste Management Board --,_ Part A- Survey BLUEOR BLACK INK PEN TPID- r Inspection Type (Fill one) Site Suffix: ��' [%) f { - j Routine Re-inspection Referral Q p Q Q Observation Local If Referral,choose referral type(Fill one) Identifier: ff a.•- c:>,., t. [�,_.,.. t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other Business or Facility Name Inspected B ;., P Y Inspector Physical Address If �J - (( r` Inspection Date City State ZlVode Time In Time Out Business Rep Title. � [TJ : L_U0AM 0 PM 0 PM �' 0 AM - Operational Status T� ( ��, Business Role Storage Type ' (Fill one only) OIJ (Fill all that apply) (Fill all that apply) (0 Active f � � Generator Q Outdoor p Q Closed GPS Latitude Q;,Pt � )r Q Hauler Q Indoor Q Inactive Longitude g ( �o Q Planned Q OTR, ala n4 Q End-Use d Container � m ,.. F sa n ess Type (Fill all that apply) Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber Q Service Station Q Hauler Q Agriculture Q Shredder Q Other Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS V A HAULING AND MANIFEST REQUIREMENTS Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline Q Q PRC§42956-Registration/Decal in Vehicle m Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB [1] [11111 Q j Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations O Q Other: § Comments Inspection Form included. • , Comments Included: Q - _ Business Rep's Signature Phone Number Inspector's Signature, Phone Number INSTRUCTIONS ON BACK_ Correct:0 Incorrect: X ,w' ""Y"�';