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Waste Tire , �& Inspection "Re Ospection Report Number <br /> ■ a€e p <br /> �G6F13"a State of California � - <br /> Ii CIWMB 181'(New 04104) S iJ'�f /J� }n( <br /> California Integrated Waste Management Board <br /> Survey rvey Form - Page 1 k 2 V (. V 6 <br /> Part A-'$urve BLUE ORB KINK PEN <br /> Business Profile Inspection Details <br /> } TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> 3 C) __1�_ 12�R [�Iil_ @ Routine 0 Re-inspection 0 Referral Q Observation <br /> Local �. If Referral;choose referral type(Fill one) <br /> Identifier: CAS O CHP O CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name r -"- <br /> -'`"'^ _ Inspected By Inspector <br /> Physical Addre s <br /> f� <br /> Street <br /> j Inspection Date <br /> G e iA <br /> y State ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> (_ ) <br /> ELI 0 PM m ' m [QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire CountWhole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( , 0 Active (5 Passenger t§ Generator Outdoor <br /> D Q Closed 0 Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> m ' <br /> 0 Q Inactive 0 Truck <br /> Longitude - Planned .OTR 0 End-Use a;Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet Q Government 0 Retreader O Dismantler 0 Tire Derived Fuel <br /> 0 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 i A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O (PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / IE / [1:1 <br /> Q Q 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 /> 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 /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462.-Manifest System Requirements for Tire Dealers or Waste Tire Generators (9) In Compliance - No Violations <br /> Q 0 Other: § <br /> Comments M , 5 lL ( t" � ! 1 Y C,C-tri f — t? C7 / �- f ��' f � ? j C' � 2, � _ <br /> prCo `� r� t i� i� "r( r,. /- �f7 n �'.,,. �; (✓ _ m ( " i��3_tL•--(- <br />} cam'•,4? <br /> Inspection Form Included: <br /> Comments Included: 0Business Rep's Si nature Phone Number InspectorsR <br /> Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: ( } ;3; 62081 <br /> ■ White Copy:CIWMB Yellow Copy:-Operator Pink Copy:LEA <br />