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Lill Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB181 <br /> Waste <br /> Survey Form - Page 1 1 4 . 1 01 4 7 7 8 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> -_Business Profile !Inspection Details <br /> TPI-)- � O � � � J � _ � / 'Inspection Type (Fill one) <br /> Site Suffix-. 0 Routine 0 Re inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0Other <br /> Business or Facility Name Inspected By Inspector <br /> %Ire, � 19h� LJ�`tQ <br /> Physical At�dress (Z'&— s <br /> Inspection Date <br /> Time In Time Out <br /> Business ep Title QAM Q AM <br /> QPM QPM <br /> [� ' r�'-• <br /> Operational Status Tire Type Business Role I Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 30 0 Active 9 Passenger 0 Generator 0 Outdoor <br /> O () Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O t0 Inactive 0 Truck <br /> Longitude — � Planned 0 OTR 0 End-Use � 0 Container <br /> Business Type (Fill all that apply) <br /> 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 f_ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS Notice Of Vloiatlon <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Ft�epplpt; <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements f Date / <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Fire Program ID Number from CIWMB <br /> Lil <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requlred:fal NQ1/gr <br /> 0 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 0 Reforred f CISi11Alf� 9i�ir <br /> 0 O <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 i ® 14 CCR§ 18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O ;ln CcmpNao # <br /> Other: § i.�✓:«//� <br /> Comments � 4— <br /> inspection Form Included: 0 <br /> Comments Included:0 ��-- <br /> Business Rep's Signature Phone Number teector's 5 gnature Phone Number <br /> INSTRUCTIONS ON BACK ICorrectso -Incorrect:j V) E P Lj <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />