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Waste Tire Su & Inspection Re Ort nspection Report Number <br /> Y p p ` <br /> Cal 3SZ � <br /> State of California ^ <br /> CIWMB181(New nage) Survey Form - Page 1 1 7 - 1 0 1 3 2 5 <br /> ifornia Integrated Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> inspection Details <br /> I <br /> TPID- ! �y 0 / Inspection Type (Fill one) <br /> Site Suffix _ Il (2) Routine O Re-inspection O Referral O Observation <br /> Local t <br /> � If Referral,choose referral type(Fill one) <br /> Identifier: Lat,y1Q� (A fl-j- O CHP O CIWMB Complaint <br /> O Educational Visit <br /> Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address I 1 i �� yt` 1 l <br /> L..-O 0-ilyl')S Pit <br /> Street l <br /> � f _ � 1 1""' Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Re _ <br /> p Title ' Q AM 7Q AM <br /> QPM QPM <br /> h.Operational Status Tire Type Business Role Storage Type <br /> L (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tlre Cunt(Wholel�'TE� <br /> Active O Passenger O Generator O Outdoor <br /> Latitude <br /> . Li LLI .O O Closed O Altered <br /> GPS i O Hauler O Indoor <br /> 0 O Inactive O Truck <br /> Longitude - [__T__T__'] �-_7—_T,_T^—�. O End-Use 0 Container <br /> O Planned O OTR <br /> Business Type (Fill all that apply) <br /> O N9w Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O 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 /> - <br /> O O PRC§42951 -Waste Tire Hauler Registration aril Transport of Tires O Notice Of Violation O Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2 Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> OO 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O Other: § <br /> Comments t c j l <br /> t f t <br /> fl, Pt L Crt�V�f Jl's�r Cx;.t �t_� r�i:�i.�.�>''✓1 <br /> t4 <br /> -Nat 7,'lr? ,. <br /> Inspection Form Included: O, <br /> Comments Included: 0 -- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: X �, A, Oil, I: i i v��p <br /> 62081. <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />