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Inspection Report Number <br /> Waste Tire S y & Inspection Repor _ _- _-_ <br /> ■ `�=3 State California m - Page 1 - 0 6 0 6 <br /> CIWMBB 181(New 04/04) Survey For g _ <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A- survey <br /> ,,...r <br /> ITPID Inspection Type (Fill one) <br />} Site Suffix: ® Routine Q Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: y! J (,fty, � �ll. •_...f Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected By Inspector <br /> r ++ <br /> Physical Address <br /> _e <br /> Street <br /> �� Inspection Date <br /> T11- c.< c , �,./1 a <br /> l <br /> City State ZIP Code Time In L] : =OAM <br /> Time Out <br /> 0 AM <br /> Business Rep Title � O PM [— O PM <br /> it <br /> Operational Statusr "y`r ,i: Business Role e `' <br /> t' (Fill one only) II' Ir ht � (Fill all that apply) ,Iftil�t1),hVI fll <br /> f a„: <br /> l.. "' li� ,�^�"r' Generator <br /> --..�0 Active <br /> Q Closedx <br /> GPS LatitudeH Lt—i d F� ) sl, �' Hauler <br /> Q Inactive ( ,✓ , <br /> p X <br /> �f sY <br /> Longitude — Q Planned0 End Use g <br /> •;,::,,-. -' <br /> ""9. ;;m'r,n«yn'" ;',;� "' ,'.,. x .1.. y" Cs r,. ,r�""�r�""•"; ✓�^S a d 'r"§'�" r. .,+': '4�i:^+ ,.iY. '�r;•`+:.;b ✓� 4F': <br /> fr <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 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 <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 /> 10 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 <br /> Q Q 14 CCR§ 18459.1 a (b) c -Tire Program ID Number from CIWMB m <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§ <br /> 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 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments (.r!✓lL Y'. f i t{'# (.cll t 1n. '� t t {\ t Z) ! [JAS J L✓ :.f lr '1 �? �i 1 '' 1 <br /> ':T i� -i ���'ir'� Ci^�1f C,A� ' r' •i o.T )4'r)I (y) (1,4 <br /> ` f G p <br /> � L � 1 1(. !J✓ t I;-,Ino iI 1 � Jli �t � �(tLt✓ i . "1` i.(% f�i {.�-i� ' _4 J � Cit�� V <br /> � ^ .���� ..",,� u�ine��� ��`� ��'�t�t�e�r .,u,.�`� Fh�n� . <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X A K. -LA'AIPILIE1 Ili <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />