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Inspection Report Number Tire S y & ns ection Report*- ,-. ---. <br /> 6 � State of California ` i; yry }Z <br /> Survey Form - Page 1 0 6 V 4T <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Surve wra�� )f <br /> r� � + <br /> �" .; �. m„�"yh '', +�^ # 5� "w��,��t�tl� �.a...—'_-•_ '—'` � tST:�f�'' ,�^�,+a.w?--.M,rz� '� <br /> TP <br /> ID- Inspection Type (Fill one) <br /> Site _ (0 Routine 0 Re inspection 0 Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ^ ��,. �� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> - k <br /> Physical Address <br /> Street p � <br /> Ins ection Date <br /> C <br /> city State ZIP Code Time In - Time Out <br /> --- _ Q <br /> Business Rep Title , --1 � O PM <br /> AM', I , 0 PM <br /> - <br /> r� „ Operational Status Tire Type Business Role Storage Type <br /> r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count Wrote/PTi �. Active Passenger Generator 0 Outdoor <br /> „ <br /> o O Closed 0Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 10 � 0 Inactive 0 Truck <br /> Lon Rude — l Planned OTR <br /> gEnd Use Container <br /> FTFT7 <br /> 0 <br /> Business Type (Fill all that apply) ' <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V AI HAULING AND MANIFEST REQUIREMENTS 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 ® 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m O m / m <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID NDmber from CIWMB <br /> 0 0 (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <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 I CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 10 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> ( <br /> Inspection Form Included: 0 <br /> Comments Included: 0 _ - <br /> Business Rep's Signature Phone Number inspector's Signature,. Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X A�, fy;A 1-0,`"' �I�1 w1 i L . <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> ■ _ <br />