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I'^ All-V <br /> Lnspeetion Report Number <br /> I� � ,.Wa; e Tire S & Inspection Report - .. <br /> r� Bo State of:California - ■ <br /> CIWMB 181/(New 04/04) Survey Form - Page 1. _ I 1-- 1 .0 10 5 Z_ "� <br /> -'-"=."�ca`lifbrnla-Integrated-Waste Management Board-- <br /> Part A- Surve - BLUE OR BLACK-INK PEN- <br /> Inspection <br /> PEN- — I <br /> i <br /> Details <br /> TPID { u I Inspection Type (Fillone) III <br /> f Site Suffix: 110101 , -/ ,. <br /> - Q Routine Re-inspection Q Referralo' Q Observation I <br /> Local If Referral,choose.referral type(Fill one) <br /> Identifier: (�[ 4/ LO�, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other_. <br /> Business or Facility Name `"+ Inspected By Inspector <br /> rl_Je,p� -Tire I / <br /> Physical fAddress <br /> I <br /> Street, (' / <br /> `— In§pe,tibn Date` <br /> -1 <br /> City State ZIP Code, Time In �; 1) Time Out <br /> BusinesstRep _` Title c O AM Q AM <br /> • O PM m m O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t J I I j I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active > Passenger to Generator (D Outdoor <br /> D I Q Closed C)Altered Q <br /> GPS Latitude m • Q Hauler Indoor <br /> 10bPl,nned <br /> Q Inactive (K)Truck <br /> Longitude – r� Container <br /> ✓' OTR t End-Use <br /> Business Type (Fill all that apply) <br /> t0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government E 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 (j) 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 /> - - <br /> .................... <br /> V A j HAULING AND MANIFEST REQUIREMENTS I <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension 1!1 <br /> Q Q PRC.§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0_0 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB i- <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 0 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 /> Com <br /> Q (5) 14 CCR§18462-Manifest System'Requirements for Tire Dealers or Waste Tire Generators <br /> In (lance No Violations <br /> p _ ions <br /> > Q Q Other: § <br /> Comments �^ <br /> > -i t`l (J'. i � ttrJ driy IriNc(Al�d 11-f SiIF � t ?5S /J <br /> '6 . -_. _ ter vu f+ 1 { Ii,( c t) <br /> .� } < ; <br /> O t_� -_c-C ' . C_ C? <tyl C( . 1,1,re <br /> j V 1 r _K'__R/'C <br /> Inspection Form Included: Q? W <br /> Comments Included: �. <br /> Business Re sgna <br /> iture_ _ _Phone Numb"e-rte Inspector's Sig ature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ,V ( ,A�1MjPjLjEj 1112 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />