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s ection Report Number <br /> -: �>s � Waste Tire Suri &--Inspection Reportft— ' <br /> p - _- --p <br /> ■ G 933• State of California I -� ■ <br /> CIWMB 181(New 04/04) Survey Form - Page 1 i 10 13 2 7 7 <br /> California Integrated Waste Management Board --- - - ---- --- <br /> Part A- Survev BLUE OR BLACK INK PEN <br /> 71 <br /> TPID <br /> - - - Inspection Type (Fill one) <br /> Site <br /> Site Suffix: `� '" �{JI Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: y; Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> if '- -- <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address - �y �V 7� <br /> Street p <br /> Ins ection Date <br /> Crtt y �! State ZIP Code Time In _ Time Out <br /> Business Rep Title AM AM <br /> �0PM L <br /> ' ��. 0P <br /> Operational Status Tire° r �� Yt'r" Business Role Storage Type <br /> i t J,"r ai <br /> (Fill one only) (Fill all (Fill all that apply) (Fill all that apply) <br /> a, ( Active Q "y Generator Q Outdoor <br /> GPS Q Closed Q Pt <br /> Latitude LLU 1 1 (f " ® Hauler Q indoor <br /> C Q Inactive Q Tri <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business`I I;se (FII all that apply)` ' <br /> €" New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATLIS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - - Q Notice Of Violation Q Extension <br /> Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 /> M / M / m <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <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 /> 010 - -- -- - --- - <br /> 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 /> ��� .to! /� �'-(�(��?f �' - � 1. y C.E' _ .✓i.,...-, '�;'``; .a� t i' ) __._ <br /> — Wr¢rl�w ✓f-kJ,"_'"" ^.: p J ig k � P y. r r b`15: "t a C<•u b4 '"r ^" ✓r• > qwk <br /> Inspection Form Included <br /> p <br /> K <br /> I ^"i s <br /> Comments Included: Q <br /> Business Rep's Signature Phone. <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X of " A c P j �� t <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />