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nspection Report Number <br /> Waste Tire Su�y & Inspection Repor, <br /> State of California <br /> gra CIWMB 181(New <br /> California Integrated Waste Managenage Survey Form - Page 1 1 1 - 10 0 0 3 Management Board . 3..._.........._1 <br /> Part A- Sma BLUE OR BLACK INK PEN <br /> FAA <br /> MN ffffzff= <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Ft Fr� F7 ;` r+ - d 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: <br /> � , _ i 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> r r <br /> Physical Address <br /> Street <br /> - •, Inspection Date / LL21 I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title I AM Q AM <br /> 0 <br /> ® PM `� l — ® PM <br /> r' Operational Status Tire Type^ Business Role <br /> ' Fill one only) Fill t apply) <br /> Tire Count(Whole/PTE) ° / f . ( ( all thata pp Y) (Fill all that pP Y) <br /> ( <br /> (DActive 0 Passenger Generator i <br /> EFI=O 0 Closed _0 Altered, <br /> GPS LatitudeLil - Hauler <br /> — O 0 Inactive a TruePlanned OTR <br /> {ct <br /> Longitude - ed R nd-Use <br /> 0 � E <br /> �. �, :�?. '°� ����.�, �' . .,;T �+ .4 ua°SIN ,� �, F •�'�'. . t^ " + '" "���"� �i. .Luau"� <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 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 /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 14 CCR 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: <br /> Comments (,". .? _ .7, <br /> Inspection Form Included: 01 - <br /> Comments Included: 0 . ... ... `_..., <br /> Business Rep's Signature Phone NumberInspector's Signature Phone Number <br /> ,.w <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X V i �A V. P L e E <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />