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Waste Tire S**,y & Inspection Reporgespection Report Number <br /> Qd31. State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 1 3 . 10 13 2 6 t' <br /> California Integrated Waste Management Board ----- --- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TFID- Inspection Type (Fill one) <br /> Site Suffix: l J I I �_ / 0 Routine 0 Re-inspection 0 Referral Q Observation <br /> Local l I If Referral,choose referral type(Fill one) <br /> Identifier: ;') il'' C11 t 4.1 l-, ' -'! 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> ( Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> State ZIP Code Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> ;1,1 O PM O PM <br /> mm7TOperational Status Tire Type Business Role Storage Type <br /> C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) t { <br /> ()Active 0 Passenger Generator 0 Outdoor <br /> D 0 Closed 0 Altered �, <br /> GPS Latitude m 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> 0 New Tire Dealer (D 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 0 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 /> 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 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/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 /> l - If r - it I i l •4 tR – —` LT t r l� f!�_ - <br /> J 1--f <br /> (Ai ', vr , ,C i(t it,, 60Cr1 1 6ir k,aI rtte� r�PCI ��c c. ft .: . ! I/t" n <br /> I�:i;' �•t {;,; � ,,„y-1.�1ti1 ,��a-lt,.lrl� is-�� iii � , � �c �l� _fZ1� 11Er, I �/� � ;I � ( �, cfi <br /> Inspection Form Included: 0 <br /> Comments Included: 0 • <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X o ,;1, L.P E 1 2131 'i <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />