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Inspection Report Number <br /> , Waste Tire Suy;& Inspection Repor -i_ p p� _ _ <br /> State of California <br /> GG3.G CIWM6181(New04/04) Survey Form - Page 1 i ° 7 6 0..^o <br /> California Integrated Waste Management Board -- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> MINE= ,, ' <br /> Business:Profile,' <br /> TPID- � Inspection Type (Fill one) <br /> Site Suffix: / (� Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> k---,L��-'- �i,.��:�-.� ����-fes.- I � _ <br /> Physical Address <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> 0 AM 0 AM <br /> Busine s Rep Title <br /> -- 1 EL _ L_.-- O PM ' O PM <br /> Operational Status Tire Type Business Role ^Star t <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (FIII ar <br /> Tire Count / ,T,11 G° ® Active Q Passenger Q Generator Q Ot o <br /> OVr G <br /> Q Closed Q Altered <br /> GPS LatitudeF1 L-1 H Q Hauler Q <br /> D Q Inactive Q Truckytr� <br /> Longitude — Q Planned Q OTR 0 End-Use Q Con ) <br /> TTI -.. <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 /> (b 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 q 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 /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> Q 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 /> Q 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 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 Q Referred I CIWMB Enforcement <br /> Q 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 Q In Compliance - No Violations <br /> 0 0 Other: § _ ._... — ._._ — -- <br /> r /I <br /> Comments4M 2 <br /> -- ----- - <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Di Business Rep's Signature Phone Number Inspector's Signature Phone Number:.. . <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:I* Incorrect: X A lkli1 PL i i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />