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Waste Tire Surma & Inspection Report <br /> Inspection Report Number <br /> Y , p p - -- - -- - - N <br /> State of California <br /> ` ®rnia CIWMB 181(New Survey Form - Page 1 '. � 5 � 1 0 0 � l 3 5 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK'PEN <br /> u <br /> TPID- EI�� Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. O CHP O CIWMB O Complaint O Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> L hysical Address <br /> Inspection Date / / EE <br /> - Time In Time Out <br /> I <br /> _- --— � - -- State ZIP Code <br /> Business Rep �N. Title Q AMQ AM <br /> Q PM Q PM <br /> -- -- <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill ail that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active 0 Passenger Q Generator 0 Outdoor <br /> GPS <br /> Latitude O O Closed O Altered <br /> 0 Hauler 0 ll7door,� <br /> --- --7�� Q Inactive 0 Truck <br /> Longitude — I O Planned O OTR End-Use Q Container <br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer O Collection O Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder Q Other — - - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 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 <br /> Q In Compliance No Violations <br /> Q 0 Other: § <br /> Comments <br /> - <br /> y .. . <br /> v&au rpvv„i.,/°r r a !: r a�'wa r hay r:v�"t...�', Y'• F1¢s rr. c"^ r t r r .7+•yr,.;1 mr � d r 7 ka <br /> � ..� { y, y�,�' 4, ,f r '”' i �Pih•u a, ^'' w,'+Y'l ,.�v.: r a' l�'�+" P <br /> ,rn+F"�,fi'± :;"-r � v,r � ra r yr+ ,. r+ ,a:, .rr,a, .: w Fa rr '; :':. y ru, -f,r ly, .11". ,,u, •r�'+ <br /> ,✓> _ ,.^�.7' y .:x,:W <br /> tIOn1M;e t5X"%I 'GCI «; wry/r< <br /> .:� , ,�I "'�.w, +" 77"""U"'7'77 r17t"rr,,.v Y" <br /> r ._ ' USiness Reps S► fYS1 Y r u �Mf>�1�; Ik " � �CS:r„ +r rp s m a <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I �, 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />