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Waste Tire S_Oey & Inspection Repo Inspection Report Number; <br /> �CtlA Stateof California ■ <br /> �a- CIWMB181(New04/04) Survey Form - Page F 1 8 - 1 D T6 .6 1 4 <br /> California Integrated Waste Management Board <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business Profile (. ` ` + G f Inspection Details <br /> TPID- i (� 91 -i - Inspection Type (Fill one) <br /> Site Suffix: f l `j g ©� Routine Q Re-inspection Q Referral Q Observation <br /> Local I <br /> If Referral,choose referral type(Fill one) <br /> Identifier: } ;1 (JC(C t., t✓\ `, (t l„ O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address (J jet, <br /> Street <br /> Inspection Date J' <br /> ! Time In Time Out r <br /> city State ZIP Code <br /> Business Rep Title Q AM <br /> PM � � � OAM <br /> I t "1 f II -- - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) l� + I (�I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Passenger Q Generator 0 Outdoor <br /> D Q Closed 0 Altered <br /> GPS Latitude m . Q Hauler 0-Indoor <br /> 0 (5 Inactive 0 Truck <br /> Longitude - O Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body (E) Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station 0 Hauler 0 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 <br /> -- Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste.Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / 11:1 / IE <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 I 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 ® In Compliance - No Violations <br /> 0 Other: § <br /> Comments <br /> it>'tf" /,i <br /> 'illr ��t� til'{ �� �f S (ASed t ttrr /VU /tf� �-✓o Gf-evi �f�c�nr r c< -- <br /> te J I <br /> I <br /> Inspection Form Included <br /> I <br /> -.- ... <br /> Comments Included. 0 - - r - '- -- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> \� rG, V 3 62081 <br /> INSTRUCTIONS ON BACK Correct:110 Incorrect: Y�j l� A M P �� I <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />�l- <br />