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�spection Report Number <br /> Waste Tire Sur & Inspection Report <br /> 62t SSate of California -CIWMB181(New04f04) Survey Form - Page 1 { I'California Integrated Waste Management Board --------- <br /> 10 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- _ _ _ Inspection Type (Fill one) <br /> Site Suffix: Fil 73 ,g I �� .' i (a Routine Q Re-inspection Q Referral Q Observation <br /> Local -� - - � -- - rr( <br /> If Referral,choose referral type(Fill one) <br /> Identifier: J: ;fes <br /> -�,L I(+'� l � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address , [� I J /t r.i,_ 1-Y-0 t; <br /> Street - <br /> i Inspection Date D � ,y7• / � (J <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title AM AM <br /> 0 PM 0 PM <br /> IL - - <br /> ~ l 4 Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply)'I (Fill all that apply) (Fill ail that apply) <br /> f: Q Active Q Passenger Q Generator Q Outdoor <br /> FF 1:D Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> �,T,_� I ��—��O Q Inactive Q Truck <br /> Longitude – i , I 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 C) 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 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 / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB M <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive 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 0 Other: <br /> Comments <br /> 4(,(! =(O 1, 0 6A)[i .f 'A )d 'S Of, <br /> r t ` '.I U �� /i,( i i' 't/� t `•/ a l` ! / <br /> rf �ru �� .�Y- � ��� �La);�- - ��(v r•.is-, <.,� �` ;�� f1 ���� Cl_� <br /> Inspection Form Included: Q <br /> Comments Included: Q Business Rep's Sig - `– – <br /> nature Phone Number Inspector's Signature Phone Number. <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X I 1----X A tM I P I L JEJ f 2 3 62081 <br /> White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA <br />