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Waste Tire Slays Inspection Repor. In. ction Report Number <br /> State of CaliforniaCWMB 1181(New 04104) <br /> California Integrated Waste Management Board Survey Form - Page 1 1 5 yV L V L V <br /> 61 <br /> 'art A- <br /> Survey BLUE OR BLACK INK PEN <br /> Business coon Details — <br /> TPID- I I I I — I I Inspection Type (Fill one) <br /> Site Suffix: `I I Q Routine 0 Re-inspection Q Referral Q Observation <br /> Local ( i If Referral,choose referral type(Fill one) <br /> Identifier: kol Lq it I l Ooki¢tf Q CHP Q CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name <br /> _ Inspected By Inspector <br /> i <br /> Physical Address' <br /> 'ltlt <br /> I <br /> Inspection Date <br /> State ZIP Code Time In Time Out <br /> Business Rep Title l i7 AIv1 I I ) . I I I (P AM <br /> QPM r J 0P <br /> Operational Statusire Type Business Role Storage Type <br /> (Fill one only) Fill all that ap (Fill all that apply) (Fill all that apply) <br /> ,, � i'; ; <br /> The Countµaunt (Whole/PT 1 O ActivePassenger Q Generator a Outdoor <br /> GPS Latitude I .I I ( I I Q Closed Altered O <br /> Hauler Indoor <br /> O Inactive O Truck - <br /> Longitudef� Planned 0 OTR End-Use Container <br /> Business Type (Fill all— at Lapp <br /> Q New Tire Dealer O Auto Repair O Trucking Fleet M Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> O Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT S'T'ATUS <br /> V A j HAULING AND MANIFEST REQUIREMENTS _ Q Notice Of Violation Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 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 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators J In Compliance - No Violations <br /> Q Q Other: § -- <br /> Comments7 <br /> F}rC,' pun(j pun( t1' f :7•lCt (eelC k- Ill I I tr <br /> J <br /> /1 i, t.��i:n-�E ��`r .l'.l IV1 1/(i"d V(1c_I l,- �1�4 �!✓ <br /> 1� fir/ <br /> rf),,,(! _ ILS ,��t­i - ti11-.✓il� I i�f ,r{ vrlr �t Yk��,^�t �iIVA( <br /> Pr I 7-t-Fe--S 0f( kintti,i <br /> Inspection Form Included: <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's_ Signatur Phone Numl <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X ii \/ j!:jXI A MI P I L I EI I 1 12 13 I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />