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x . 411 —RtL-z -4111111111W. AW - A j., _WT . -.a. _ <br /> Waste Tire Su- :y & Inspection Repor Inspection Report Number <br /> U State California Survey Form - Page 1 a - Q Q <br /> CIWMBB 181 New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> i TPID- I ' I � �F91 <br /> - [�L/ <br /> Inspection Type (Fill one) <br /> Site Suffix: j y ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: : ( i t /1 0Oy t j 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 0 1 <br /> ' r <br /> 4.Street <br /> { r- Ins ection Date <br /> L <br /> Jrti��tc�t E If `,U CA q- ,) <br /> p <br /> city V State ZIP Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> r � �QPM _ QPM <br /> eTire <br /> Operational Status Tire Type Business Role Storage Type <br /> Count (Whole/PTE G Ozol <br /> (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> Q Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0`Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - , 0 Planned 0 OTR End Use 0 Container <br /> apply) <br /> 0 New Tire Dealer 0 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 /> HAULING AND MANIFEST REQUIREMENTS <br /> --- 0 Notice Of Violation 0 Extension <br /> 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 1 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 I PRC§42956-Registration/Decal in Vehicle <br /> 0 0 1 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date T / m / M <br /> 0 0 1 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 1 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 O In Compliance No Violations <br /> 0 0 Other: <br /> CommentsL� IY r I i <br /> 40 <br /> W' <br /> tS W �L�for <br /> `t t,L} ( - U>" I�L4 I(� <br /> I Lit/ (? I `l yj _�i�d Q "_i r►tit �� / ��i�; a ' JI Cl nG� _a <br /> o(l�c+_vt I i S(. c., �c:� /'� V'0 <br /> 1 ' <br /> Inspection Form Included: 0 <br /> Comments Included: 0 L <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 6201 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X '=:= y:j +. ,'.' r' Ir I f i :_ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />