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Waste Tire Su Y p Reporo Inspection Re orolnspection Report Number <br /> Qq <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 2 10 1 0 8 9 9 <br /> California Integrated Waste Management Board -- - - - - <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> TPID- I � � � �F071 <br /> Inspection Type (Fill one)Site Suffix: Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: t,11 n O Ur <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other , <br /> Business or Facility Name Inspected By Inspector <br /> L _ . _ <br /> Physical Address I Q I <br /> I ' Ll L C . W-ft_c or, KcA. <br /> Street =0 �Inspection Date <br /> City State ZIP Code ITiimeIe In Time <br /> Time Out <br /> Business Rep Title W : 0 AM <br /> 0 PM H O PM <br /> 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 Q Passenger Q Generator Q Outdoor <br /> GPS LatitudeO ® Closed Q Altered <br /> m • <br /> Q Hauler Q Indoor <br /> r — 0 Q Inactive Q Truck <br /> Longitude – I Q End-Use Q Container <br /> Q Planned Q OTR <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 /> ® 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 <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 / FT] <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 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 I 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 OOther: §, I <br /> \�, ,� <br /> Comments 7 Oke W*)n () (A)Vn-r M aV1)O n ah M Car_\\ \i1 hQ <br /> co'n�w tvud --Vhc\� C)ticricA\on:-, arc no ton �p_r c cLrd'Ac AC4 c -t1�► <br /> Inc-aha ori . All Fires have beer, CFmt1yed rom site. !DhrW. -1 ire 'j il�+ -al <br /> -.-.. <br /> Inspection Form Included: Q <br /> s <br /> Comments Included: Q -' <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X - X2081 <br /> "�. j. i <br /> White Copy:CIWMB Yellow Copy Operator Pink Copp y LEA <br />