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Inspection Report Number <br /> Waste Tire Sy & Inspection Reporow. ■ <br /> State of California <br /> ®s.�s CIWMB181(New04104) Survey Form - Page 1 1 10 205 *171 -3 <br /> California Integrated Waste Management Board - -- - - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> , 'd <br /> Business Profile ; l <br /> TPID- �} ) —y Inspection Type (Fill one) <br /> Site Suffix: ' ;{ (i ) ✓ 1 (Z) Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: f 1 j o-( , :;{ r t,( ,, { yl ..+ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> J. <br /> Business or Facility Name .' Inspected By Inspector <br /> Ii,j ( <br /> Physical Address <br /> Street <br /> t Inspection Date c` <br /> city State ZIP Code I Time In Time Out <br /> Business Rep Title Ei_� : � <br /> O AM O AM <br /> IMIN <br /> r .operational Status Tire "'� Business Role Storage Type <br /> (Fill one only) (Fill aIIIl ( (Fill all that apply) (Fill all that apply) <br /> (a Active 0cF�,��� Q Generator 0 Outdoor <br /> D 0 Closed 0',A)�t�rC� `�' �� <br /> ° ' 0 Hauler DIndoor <br /> 0 Olnactive O'Truck�U�;�' "� <br /> Longitude — 0 Planned 0 OTR 0 End Use 0 Container <br /> Business Type (Fill ail that apply) <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 (2) Other t 7 r( { <br /> L <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V <br /> i AHAULING AND MANIFEST REQUIREMENTS 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 1 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I 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 /> t,;;,1 <br /> 16 RJ, i. <br /> Yl Vol 4' %t I t�f (. r i E..��J t �. i+ (? .t v a <br /> C1 . <br /> Inspection Form Included: 0' <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X I r:`A 14(�" Ill"., A <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />