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Waste Tire S y & Inspection Report spection Report Number <br /> Survey Form - Page <br /> - ---- -- ■ <br /> ®7a`pa9 State of California Y J e . — - -- <br /> CIWMB 181(New 04/04) � 10 1 """"rVVV111 <br /> California Integrated Waste,Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> InSpeCt1f1t1 �r � r'FFilunff- <br /> g; y' rty ff rl ayrr K "im M a <br /> TPID- _ Inspection Type (Fill nre) �r�z <br /> Site Suffix: >� <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local <br /> Identifier: If Referral,choose referral type(Fill one) <br /> j <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name /. <br /> Inspected By Inspector <br /> — n <br /> lir_. J - <br /> Physical Address f <br /> --___I <br /> Street <br /> Inspection Date <br /> City State Ztp Cade Time In Time Out <br /> Business Rep Title QAM <br /> AM <br /> PM O PM <br /> I_.. <br /> Operational Status Tire Type Business Role Storage Type <br /> E111111111,IIIIIIIN <br /> (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude EE - L I I _T=0 >✓ Hauler Q Indoor"i� <br /> o Q inactive Q Truck <br /> p <br /> Longitude — Q Planned Q,CT 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 a Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STA_TUS_ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> — - -- ------- -- <br /> Q Q ,PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 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 / <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m m m <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 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> r <br /> J ('�{� ��,(...� t,i !I ti.•_ �'f�i� f �+ ! <br /> r <br /> �/ <br /> Inspection Form Included: Q' <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X A�, 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />