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pfS.t. .. tO[i1W�3 A5w .ap.rll. -:..�- ---155.9, L;1-i_. 1 <br /> Waste Tire Su�& Inspection Report4^-- Report Number <br /> .•rf�l7ll State of California /'� ,� /� A <br /> Calif InC,WMB181(New04/04tegrated Waste mentBoard Survey Form - Page 1 1 v - 1 v 1 � 1 - 4- 6 <br /> Part A- Survey BLUE`OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Inspection Type (Fill one) <br /> Site Suffix: <br /> TPID- � I( I �f -7 y � Q Routine Q Re-inspection Q Referral (P{observation <br /> Local ( If Referral,choose referral type(Fill one) <br /> Identifier: 0(t 1. 1/t4,r.l (C(,q/, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 1 . ,t <br /> Street <br /> r Inspection Date V f� '7. <br /> State ZIP Code Time In Time Out <br /> Business Rep Title0 AM <br /> �`}�11� <br /> l� Q AM OPMV0 PM C/ J <br /> Operational Status ire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) Jr <br /> ® Active Q Passenger (4 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude f I I , Q Hauler Q Indoor <br /> W O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all thaal <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 / 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 /> 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 /> Commentsf r✓e' i 't!" i .t i ' i'I <br /> �j Qk,� yt(JrLi I I j C(Iio l ��: t" I i:, ; //1t U��< <br /> (� a �0rv�CP ti(I �Itf + w ��� Clo ( �Q�� t. Jr �r �C.1 <br /> Q P{ n��t. 11�r� u <br /> >l( c t t _�1 r(y 1 (k'c:(J ';'�/sn.� �r�f "f(f� pul l_ LCfr/cc�u/r� l.()l� t� t I/f- <br /> � J <br /> Inspection Form Included: ; <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X _EX_ <br /> A MIP I L I E 1 1112 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />