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Inspection Report Number <br /> Waste Tire Sul& & Inspection Report _ - <br /> State of California -f <br /> CIWMB181(New 04/04) Survey Form - Page 1 1 3 - .1 0 1 3 6 4 1 <br /> California Integrated Waste Management Board - -- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: / I /T71 7[�7 L21 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ��—�— / If Referral,choose referral type(Fill one) <br /> Identifier. "''l'Z /��/✓.{� �, I' .0- - – 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> i� <br /> Physical Address <br /> Street _ <br /> f Inspection Date/ EE? <br /> CityState ZIP Code Time In Time Out <br /> Business Rep Title ® AM 0 AM <br /> �/ O PM O PM <br /> -amOperational Status f ft �a Business Role Storage Type <br /> WPM <br /> 1irIe taunt(Whole1PTE) <br /> (Fill one only) (Fll ( pAlya (Fill all that apply) (Fill all that apply) <br /> , � <br /> Q <br /> Active ® Generator 0 Outdoor <br /> �✓,r 'kz �d � <br /> 0 0 Closed O� Ierrw „ <br /> �r r, <br /> _LL <br /> GPS Latitude 11 <br /> i ", 0 Hauler 0 Indoor <br /> 0 0 Inactive ( TruCk <br /> Longitude 0 Planned 00 0 End-Use 0 Container <br /> WT� TU70p—In, 777,1,j <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 /> f V A HAULING AND MANIFEST REQUIREMENTS <br /> ------------- <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 VVhicle <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 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /><: <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 <br /> °-l�'I /- 'ter !•f }// -�fF� �/ !-Gt �.��_! f/ i� d..- cr_.i>>L�C- -��`- !�. <br /> Inspection Form Included: 01 <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 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />