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■ Waste Tire Surfty & Inspection Repor _Inspection Report Number <br /> State of California -- - ■ <br /> QaAav9 CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Survey Form - Page 1 10 1 0 _ -5 7 <br /> Part A Survey _ BLUE OR BLACK INK PEN <br /> , u v <br /> ',r.47'r r p rH ? ;:t @T 1✓rr�:H tx `✓ ✓ 3 a!l wr ti+?)H,✓' �n7 ✓,f 1 4' ,> > r r '::9 ti ✓ * I��� ?, ' %', ,� n v r r>, � �,,;n;�: r�+yr i r�;v,kn rr�ni r„r„i,„ nW h�,r a� s^uh% hi q�Yy tl M I�” ,l� v «✓n ,+ r�n rl�;r f <br /> �✓.,.�.<., nd `""�M°�"i„""� l.n. ,✓w,,�r�;r P�iL(w.n "'"1^h Mfi..,,_ kf.�� " __- rr"1^»,�2_,✓�Y',w ��i�I _..._�._ _ 4� '�v"��vc._wnr {��.��?'��.,.:..✓�., Sd..vw 1p <br /> TPID FF r- 4 v Inspection Type (Fill one) <br /> Site Suffix: f 1 ( `;� I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local n '� If Referral,choose referral type(Fill one) <br /> Identifier: '(:i c1!t '.r!t`.0-E 1 \ !%`f; :;,, - QCHP Q CIWMB Complaint Q Educational Visit Other <br /> Business or Facility Name % Ins ected B <br /> P y Inspector <br /> Physical Address < - I J1 <br /> f`) J � <br /> �:. <br /> y <br /> _ <br /> (�J iI, d ( i <br /> l yj Ct�i. ' a C T <br /> _YT <br /> Street -� <br /> �- �-� � �, _ •__ Inspection Date <br /> � r. <br /> City State ZIP Code Time In EF]0 AM Time Out <br /> Rep Title <br /> PM <br /> m AM <br /> O PM O <br /> Business � ` ' <br /> MEN=HEMMMM Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude TD Q Closed Q Altered GPS m . Q Hauler Q Indoor <br /> l� L0 Q Inactive Q Truck <br /> Longitude - 1 Q Planned Q 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 Q 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 <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Notice Of Violation Q Extension <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 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 /> 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/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 <br /> Q In Compliance - No Violations <br /> 0 Other: § <br /> Comments <br /> 1 ,l t11.J <br /> t I 1'11 'lr+,tt� r '�tJC2�.:�; t �� I <br /> Inspection Form Included: Q' <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> Y 62081 <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: _ ,r: ,�,, w_A l- L �° <br /> ■ _ ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />