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L! <br /> =? Inspection Report Number <br /> Waste Tire Su&y & Inspection Report <br /> iC•3. State of CaliforniaCIWMB 181 04/04) <br /> �/'�j /}�� <br /> Califom>�Integrated Was eeManagement Board Survey Form - Page 1 I 1 2 - 1 N 1 V`j'�i i/ 1 8 <br /> Sart A-Survey BLUE OR BLACK INK PEN <br /> nspection Details <br /> TPID- 1 L1 ( �� I ( t �l - /, i I I Inspection Type (Fill one) <br /> Site Suffix: r 1 V 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> � Inspected By Inspector <br /> Me , <br /> Physical Address <br /> )ICA G r/ 1 lel S� • I - - <br /> Street <br /> 6';S <br /> Inspection Date <br /> City Safe ZIP Code Time In Time Out <br /> Business Rep Title / O AM O AM <br /> Operational Status Tire Type 7 Business Role Storage Typ <br /> (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that ap' <br /> Tire Count (Whole/PTE'' I i <br /> (a Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude '^ <br /> t O 0 Closed 0 Altered <br /> GPS l 0 Hauler 0 Indoor <br /> I I <br /> 0 Inactive 0 Truck <br /> Longitude 0 Planned 0 OT 0 End-Use 0 Container <br /> Business Type (Fill-�67 at applY7 <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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 1 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 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 FF / 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 F�01 rug lw-7oy C lo)l - /6-t <� d_ a- <br /> fe /kC' lJ1r' t Wo Yl C� <br /> "? I dr�f �rz -_�_���1u�,t ` 1�'��_ <br /> t ' <br /> I ' Iii L > u Q a ti�J�A' 11 � (� CLC t,a j f��IS f Jf ly:1 'r ef� H <br /> ��► -4 -r�= , ' I()1! J 0 1 no - �f Jt �I111--ltuA � 111) ,01 <br /> Inspection d <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Numbe ._ <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X F'X� ,°t�tl p,�,I � I 1 62081 <br /> White Copy.Cim)MB Y„Iluv C, Pink Copy:LEA <br />