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ns ectlon Report Number <br /> Waste Tire SLW & Inspection Repor p __-p _ - <br /> ..rn Survey Form - Page 1 2 - -� Q Q Q 3 Q <br /> - -r�Q °' State of California I <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board 0 <br /> Part A- Survey BLUE OR BLACK INK PEN <br />} TPID- C� - [�Z_ <br /> Inspection Type (Fill one) <br /> Site <br /> Site Suffix: <br /> Q Routine Q Re-inspection 0 Referral (a Observation <br /> t <br /> i <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: —� J ., .; — �r, �OCHP O CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name <br /> • IInspected By Inspector <br /> ` Physical Address 0 ' <br /> Street <br /> --� Inspection Date <br /> Cifv State ZIP Code Time In Time Out <br /> Business Rep Title <br /> �C_� <br /> ®AM O AM <br /> Q PM f C O PM <br /> - Operational Statusire"` ype Business RoleDrage Type <br /> Tire Count(Whole/P .. <br /> (Fill one only) (Fill all that apply) (Fill all that apply) all that apply) <br /> 101 <br /> Active Q Passenger O Generator utdoor <br /> O Q Closed Q Altered <br /> Latitude m . <br /> GPS Q Hauler 'Q Indoor <br /> MO Q Inactive 0Truck <br /> ` <br /> Longitude g Q Planned Q OTR 0 End-Use 0 Container <br /> 1. <br /> WONew Tire Dealer O Auto Repair O Trucking Fleet Q Government O Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler O Agriculture Q Shredder ® Other r tom, <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> s I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation 0 Extension <br /> 0 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 (a 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> i. � <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 1 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> O O 1 Other: § <br /> ey <br /> Comments ; <br /> 7 <br /> Ins peG wrt orm- n uded: Q <br /> Comments Included: 5 p <br /> Ql Business Rep's Signature Phone Number Inspector's Signature Phone <br /> X /' L� ' I� T o 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X R ,Jt P L Ir 1 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />