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Waste Tire Su@6y & Inspection Reporm Inspection Report Number <br /> i17L State of CaliforniaCIWMB 181 R //� j'� <br /> California Int grated Was"e Management Board ew 04/04) Survey Form - Page 1 1 V - 1 0 L 5 V 451 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details .� <br /> �TPID- � G- - Inspection Type (Fill one) <br /> Site Suffix: Routine Q Re-inspection Q Referral Q Observation <br /> Local ' If Referral,choose referral type(Fill one) <br /> Identifier: "( �. -j U(t ti I el C (�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U> Inspected By Inspector <br /> Physical Address 3 / l Q / A C <br /> - <br /> Street <br /> G Inspection Date <br /> I S1 �foH �� / S �0 0 , V 1 lam' v <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title AM Q AM <br /> N1 <br /> � • �0PM 0 P <br /> Operational Status +re Type Business Role torage Type <br /> ire Count (Whole/PT (Fill one only) r(Fill all that apply) (Fill all that apply) Fill all that apply) <br /> 5 ®Active Q Passeng Generator Outdoor <br /> m0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q 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 M / FTI / M <br /> Q Q 1 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 /> Q Q 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 "I lire <br /> A `-ij fur .� l ov <br /> Inspection Form Included: O <br /> . <br /> Comments Included: Q <br /> Business Rep's SignaWre Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X > t 2 31 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA <br />