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Inspection Report Number <br /> Waste Tire Su&y & Inspection Repor p p <br /> ' •�' State of California . <br /> -99,T"s9 CIWMB181(New04/04) Survey Form - Page 1 -� 7 a ,� <br /> California Integrated Waste Management Board J J ----- -- - ---- <br /> 3 5 19 <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Inspection Details <br /> Inspection Type (Fill one) <br /> TPID- <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local – If Referral,choose referral type(Fill one) <br /> Identifier: �',.�f% ;'1 }`o �' i.;r t , `)?.'t -� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Tr'`.- f_� '� � Q e Inspected By Inspector <br /> I_- <br /> Physical Address <br /> Street <br /> Inspection Date <br /> r r { <br /> City State,ZIP Code I' Time In _ Time Out <br /> Business Rep Title l O AM O AM <br /> O PM ®_ O PM <br /> I Operational Status 7 d I Business Role Storage Type <br /> /Tire Count(Whole/PTE) (Fill one only) (Fail II4 ;� #pkv!ti (Fill all that apply) (Fill all that apply) <br /> ' ® Active ( A gr " (6 Generator Q Outdoor <br /> Latitude r O Q Closed ltrer �, . <br /> GPS Q Hauler Q Indoor <br /> — - O Q Inactive t .IrWC <br /> LongitudeTI Q Planned Q OTR Q End-Use Q Container <br /> Business"Type (Pili allthat 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other i <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / 71 / m <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 1 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 O Other: § --- <br /> Comments <br /> � <br /> 1 1.1 <br /> r <br /> ot <br /> y 47T0 <br /> Inspection Form Included: Q <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> e - _ 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � E XI A MI lP I L'I I <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� <br />