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Waste Tire Suy & Inspection Repo Inspection Report Number <br /> ■ �:.. ■ <br /> ssss,� State of California <br /> k."I <br /> CIWM6181(New 04104) Survey Form - Page. 1 I 1 6 - 10 .1 O .l 4 <br /> 'California Integrated Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> II} TPID- //�� !!�� / �) - Inspection Type (Fill one) <br /> Site Suffix: tJ l� f f V / Q Routine Q Re-inspections Q Referral Observation <br /> Local /^t t If Referral,choose referral type(Fill one) <br /> Identifier: ( (i trt t 17 <br /> �I Y�1 +�� {f..C1� ` ;3 Q CHP Q CIWMB Q Complaint ,Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 1 V rY?i{ ar(? �P , <br /> i O fel. VU I Vt� <br /> Street <br /> rti / f Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 5mm0PM 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active t Passenger (5 Generator Outdoor <br /> O Q Closed Altered <br /> GPS Latitude m . (C) Hauler Q Indoor <br /> O Q Inactive- Truck <br /> Longitude - Q Planned OTR End-Use ta�Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government @ 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 I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and-End-Use Facility .ENFORCEMENT STATUS_ <br /> V ! A HAULING AND MANIFEST REQUIREMENTS @ 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 /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date1M31 <br /> Mo - <br /> 0 <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB FGflg O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> _...... -".-.--.............. <br /> - <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O . 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§.18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> for Tire Dealers or Waste <br /> 14 CCR§18462-Manifest System Requirements .Tire Generators <br /> O O ` / _,• Q In Compliance - No Violations <br /> O Other: § lt! (' c`" ti f� 1 C't.Vlr' <br /> Comments irk C (( " r .P <br /> �' •I0 S �.:4)PCcd� C.t ��-P C�. 1Gf .oc•1�� _�! )� (A ,(�� �.�� � IP�' <br /> 0+FlD-1' Nri _►�� �` �'7L rpc��-li�T Ll �1taa� /%raY����l Tre TAID� <br /> Inspection Form Included 01i <br /> i C <br /> Comments Included S" <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> r�, 62081 <br /> INSTRUCTIONS ON BACC`K� Correct:� Incorrect: X w � !<3X .A'M!I l?I,L E 1 11112 3 <br /> ■ ' hite py:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> I <br />