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Waste Tire Sure& Inspection Report pection Report Number <br /> State of California - I A fi <br /> CIWMB181(New 04104) Survey Form - Page 1 $ - 10 1 J 7 2 U i <br /> California Integrated Waste Management Board J J <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I I I I - I Inspection Type (Fill one) <br /> Site Suffix: I Q Routine Q Re-inspection Q Referral Q Observation <br /> Local I^ If Referral,choose referral type(Fill one) <br /> Identifier: Usk t�. ( �} �+ r Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name \_ Inspected By Inspector <br /> A iC 11�K �' f TjiJ <br /> Physical Address 1 I I �I I (� r 1{Iyt y, t ;,r � <br /> I <br /> v v b't t _ /-c I <br /> ,r 11r Inspection Date I V <br /> State ZIP Cod Time In Time Out <br /> Business Rep Title O AM O AM <br /> A ;,�d(nc �' ( . QPM I I I 10PM <br /> .i Operational Status Tire Type Business Role torage Type <br /> Tire Count (Whole/PTE nl (FjJI one only) (Fill all that apply) (Fill all that apply) Fill all that apply) <br /> f (�Active <br /> GPS Latitude Q Passenger ! tr Generator Outdoor <br /> Q Closed Q Altered <br /> Q Hauler Indoor <br /> Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use ontainer <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q 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 STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q 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 <br /> M / M / m <br /> Q Q 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 /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> , J i <br /> i-�7_'.t-' llY';� 1 �� s��f� t;.l � y���1',.i✓�� �i16t1'�F�[� �� � �� � ; qtr i <br /> f r — <br /> l �1✓l�`.� :,,�� I vI ' 1 <br /> Inspection Form Include , <br /> Comments Included: Business Rep's Signature Phone Number Inspector's Signatur <br /> Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 1�_ V( E,X I A JVi I 1 P L 'E 1 2 31 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� <br />