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Waste Tire Su. ;y & Inspection Reporto <br /> Inspection Report Number <br /> �� ��• State of California <br /> iygy CIWMB 181( e ) Survey Form - Page 1 1 Z - 1 0 1 3 7 1 Z l <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> 0ffi <br /> Suffix:ux: '7 <br />} � V I I ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: )GAG{610 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address I ' y <br /> slree` <br /> A ��' '� C Inspection Date <br /> State ZIP Code Time In lJ Time Out CJ vi <br /> Business Rep Title l AM ' AM <br /> �®0P / f I I 10PM <br /> Operational Status ire Type Business Role forage ype <br /> Tire Count Whole/PT (Fill one only) ill all that apply) (Fill all that apply) (Fill all that apply)', <br /> ( I J Active Passenger Generator Outdoor <br /> 0 0 Closed 0 Altered <br /> Latitude <br /> GPS 0 Hauler door <br /> v <br /> 0 Inactive 0 Truck <br /> Longitude — 0 Planned OTR 0 End Use nt i <br /> B at app <br /> 0 New Tire Dealer 0 Auto Repair ® 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 I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT S'TA"i U6 <br /> _V A 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 /> •' <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 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 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 /> Comments tifoIMoir <br /> J r ( <br /> tl <br /> r <br /> 1 %; 61, 1."I rt I torr— t�,11 , It N f o f D tr �f--k5 -'. �e� TirL� c?�� J I at ..� <br /> E��1 E C7 Yra s a ki <br /> / 1 <br /> f <br /> v T;1 �� ;j� a r�° I: ;off! a✓t r.! , t < i t c. i,�- ,r©(-(r et i <br /> Inspection o nc e <br /> Comments Included: 0Business Rep's Signature -` <br /> Phone Number Inspector's_ Signre <br /> INSTRUCTIONS ON BACK Correct: p Incorrect: X Yi P 9 l_I EI I 112131 <br /> 62081 <br /> r White Copy CIWMB e!low Copy Pink Copy.LEA <br />