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= H Waste Tire Sur .y & Inspection Report inspection Report Number <br /> „o <br /> State of Survey Form - Page 1 - 0 7 <br /> CIWMBB181(New 04104) <br /> California Integrated Waste Management Board <br /> 5 11 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- Inspection 7 - Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local - :4 If Referral,choose referral type(Fill one) <br /> Identifier: l I` f tti ( t Il f Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I // Inspected By Inspector <br /> Physical Address <br /> . LLL'--III--111 <br /> AX <br /> StrPP,t t f <br /> / Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title ( (� • (��0 AM m :m QAM <br /> t W W PM O� IBJ PM <br /> ;F Operational Status][Fire Type Business Role Storage Type <br /> Tire Count (Whole/PTS Q _ <br /> (Fill one only) r(Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Passenger Q Generator Q Outdoor <br /> O QClosesl_... Q Altered <br /> GPS Latitude m • ,}' Q Hauler Q Indoor <br /> O! ® Inactive , Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <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 >�i ( .,`y!''J(!st t;i�t,•�! r '.r <br /> L--s -- - ---- -ter <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 0 ' 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 1 Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or 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/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 /> �'� <br /> r",f` i 3 - t YJ t J// <br /> C" '•{�S/ <br /> 0 It f", 1 6,1 ��,i I � �O !Aja `J e tile eJ oo <br /> IJ <br /> eZ. , PCJY►1A/V ell <br /> . r'.' jy1C �lr" Jt-i.1` <br /> Inspecfion Form Ided: Q <br /> Comments Included: O Business Rep's Signature Phone Number Inspector's Signature. Phone Number <br /> �,,� <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X A 0'0,11 F JLJEJ 11 2 3 62081 <br /> White Copy:CIWMB Yellow Copy Operatot Pink Copy:LEA <br />