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Waste Tire Su <br /> ■ y Sc Inspection Repor`Inspection Report Number ■ <br /> State of California Survey Form - Page 1 1 - 1 0 .1 0 5 7 0 <br /> CIWMB 181(N w 04/04) <br /> California Integrated Was Management Board -. <br /> Parts A- Survey BLUE OR BLACK INK PEN <br /> TPID- 1 Inspection Type (Fill one) <br /> Site Suffix: I - [All <br /> Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: );�� j. (7` '. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (� Inspected By Inspector <br /> { If T ((' I J-1. <br /> Physical Address <br /> [ Ell <br /> I —► <br /> Streei <br /> A Inspection Date ( � � j / E,,,,, <br /> ' <br /> r <br /> 1- �) <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title AM f _ Q AM <br /> �(. t/ ,/3C O PM h�� ._ _� O PM <br /> I 1 �t'T �t 16 t 11 1 1ti .F <br /> k1 , .. <br /> ag! m r�, , A mac, Operational Status TireTypertQ, ," Business Role Storage Type <br /> ( (Fill all that a <br /> Fill one only) (a (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ) , <br /> ' rrt Active Q Passenger Q Generator 0 Outdoor <br /> . <br /> z, <br /> O Q Closed Q Altered <br /> GPS Latitude �-� . Q Hauler Q Indoor <br /> Truck <br /> uck <br /> 0 Q Inactive Q _ <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 /> U , A HAULING AND MANIFEST REQUIREMENTS 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 <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 ar 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 I 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 <br /> Inspection Form Included: Q, <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X t;; A ,0&0, I._ l <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />