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Waste Tire Su,*y & Inspection Repor Inspection Report Number <br /> State of California <br /> CWMB <br /> 181 I l1088318 <br /> California Integrated Waste Manageiment Board Survey Form - Page 1 <br /> Part A,,.,.. --.-� <br /> BLUE OR BLACK INK PEN <br /> urV _ inspection Details <br /> TPID- ,.t , ,} Inspection Type (Fill one) <br /> Site Suffix: lJ <br /> L <br /> L' �1 I I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> [AI I i ]_ <br /> Local i"'t If Referral,choose referral type(Fill one) <br /> Identifier: (v1 _- ,;,i ((� 1 �Y,-f t; 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name f J <br /> Inspected By Inspector <br /> VJ_'i I rYl o, >-4 I <br /> Physical Address <br /> Sh 'et <br /> i , J .�n1` Inspection Date I 7 <br /> � State ZIP Code <br /> Time In Time Out <br /> Business Rep Title O AM �, ( 0 AM <br /> LI-P5 <br /> O PM (7) PM <br /> 00 Operational Status Tire Type Business Role to' <br /> Type <br /> �7 <br /> (Fill one only) (Fill all that apply) (Fill all that <br /> Tire Count(Whole/PTE) apply) •,(Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude m • 0 Hauler 0 Indoor <br /> !Q 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all thatp <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 /> V A HAULING AND MANIFEST REQUIREMENTS <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 Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive 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 /> 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 /> � } i / ' — ( + I r <br /> �1 � ! , ( _ � {1 ( _f-- <br /> F � <br /> / <<<-`_W E ),T <br /> r V).�'jAI e ,.� 1'x)0 l�!'0)rA � ��r✓_1-„ � �f� <br /> f <br /> InspectionComme is Ir>�luded. Y � �� . <br /> 07 <br /> t <br /> QII, usiness Rep's Signature Phone Number Inspector's Signature _PhoneNumber <br /> INSTRUCTIONS ON BACK Correct:b Incorrect: X "� V �_x ,It�,TI L i f_, Z I 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />