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I <br /> :. Waste Tire Su & Inspection Reporlospuction Report Numt. <br /> State of California I A <br /> CIWMB181 <br /> Waste <br /> eManage) Survey Form - Page 1 1 4 - 1 0 1 3 4 0 E <br /> California Integrated Waste Management Board -._._.. - ..._ . <br /> rt A- Surve BLUE OR BLACK INK PEN <br /> Inspection Details <br /> } TPID- l 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: _�r..'t. CL-, ,r ( i� r._f= Q CHP 0 CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> --- -- --— <br /> Physical Address <br /> Street 'V _ <br /> f O Inspection Datei <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title Q AM ®AM <br /> _ / <br /> ,, � <br /> L t— I Ger , Operational Status Tire Type Business Role Storage Type <br /> iJ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> '� ® Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude • IT <br /> O 0 Closed 0 Altered <br /> GP$ � Hauler -0 indoor <br /> 0 Inactive 0 Truck <br /> Longitude – � • 71__F O 0 planned0 OTR 0 End-Use 0 Container <br /> Ms°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 /> 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ID 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <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 Date 111 / [I] / [E <br /> 0 0 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 I 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 <br /> 0 In Compliance No Violations <br /> 0 0 Other: § <br /> ------------ <br /> Comments <br /> _. �. <br /> 7` d ! rit./0c/e <br /> ?r Ile <br /> Inspection Form Included (� <br /> .Comments Included. <br /> lsiness 12ep`s~Signature Phone`Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X Fr X A M _7362081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> IL <br />