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- r <br /> ., Ins ection Report Number <br /> Waste Tire SLAW & inspection Repor p p <br /> -Lod" <br /> ''s°� State of California <br /> od CIWMB181(hew 04/04) Survey Form - Page 1 [ 1 1 01 .3 0 5,0 J <br /> California Integrated Wasfe.Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br />+ TPID- t r / _ J Inspection Type (Fill one) <br /> Site.Suffix: I / ! I rJ ( Routine Q Re-inspection Q Referral Q Observation <br /> LocalI If Referral,choose referral type(Fill one) <br /> Identifier: (` t,� �"C ,.t 0'( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 4 --— - - --- �I <br /> t Inspected By Inspector <br /> Physical Address ( /�b1 t: "f�t•i (7 <br /> r, I ox <br /> i Street <br /> J t C C Inspection Date E /� <br /> t(. C ( � 1 /� *f _J ITime In Time Out <br /> City State ZIP Code <br /> Business Rep Title O AM O AM <br /> > / ( FF10PM 0 P <br /> Lh t s'i �(�V i 1(( iG�, (/ Vl(f fill(�f1�f?<(v�. -- -- — - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 0,=,[M <br /> (Filloneonly) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Passenger Q Generator Outdoor <br /> O Q Closed Q'Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q.Inactive [ Truck <br /> Longitude - Q Planned (3,'OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair, Q Trucking Fleet Q Government Retreader^r Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto'Body Q Car Dealer Q Collection Q Crumb Rubber - <br /> 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 j <br /> V , A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension i <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 /> ................--..-. ._-. .. ... <br /> Q Q - - <br /> 14 CCR§18459.3 Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q G 14 CCRI 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 /> Q Q'. 14 CCRj.�18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q <br /> Comments 'ti�•( I' it _llt f� :�-(C� �{.0 ";:)f� L`;:,)t✓ �JQS /1 O�{ ?fNk�a� i fel+t'( <br /> i , J <br /> fadOGc.�n► i ? f& Stmt _fir ('rr����i,PIS _Jheoa`tI {arl( rP1Y1 /`� <br /> G' <br /> _V VtCC -M(01(LC'Cr . Aft - /q CC's <br /> Inspection Form Included: I <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ' t; A[MP ,� .E 2 1 3 62081 <br /> ■ Wilhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> + R r <br />