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Waste Tire Sy Sc Inspection Repo nspection Report Number <br /> ■ ` -.5 a3i'.8 State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 - $ <br /> California Integrated Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Details <br />} TPID- Inspection m Inspection Type (Fill one) <br /> Site Suffix: r^, <br /> `✓ � I(&Routine O Re-inspection O Referral O Observation <br /> LIdentifier ocai If Referral,choose referral type(Fill one) <br /> , i <br /> _ - �%�_ e• ( � -„- r �-.,s. O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected B <br /> P y Inspector <br /> Physical Address <br /> Street <br /> �^ F Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title <br /> T1QAM 0A <br /> _L0 PM QPM <br /> IN NINE Islillilgingizil 111all! Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active O Passenger O Generator O Outdoor <br /> PSLatitude <br /> OyO Closed O Altered <br /> GLm . <br /> O Hauler O Indoor <br /> O O Inactive 0Truck <br /> Longitude — O Planned O OTR O End-Use O Container <br /> (0 New Tire Dealer O Auto Repair Q Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O 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 /> ----- ---- - --- - — O Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> 0 O ' 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / EJ / 111 <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> OO 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ' <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities — <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O in Compliance - No Violations <br /> D O Other: § <br /> Comments <br /> I -� J, <br /> 1 rt <br /> spection Form Included: <br /> Comments Included. O Business Rep's�' Signature Phone Number r Inspector's Signature Phone Number <br /> ”-`" — <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X ?�, !- 62081 <br /> White Copy:CIWMB Yellow Copy:Operator _ Pink Copy:LEA ® S <br />