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= Waste Tire Sulwy & Inspection Reports Inspection Report Number <br /> State of California Survey Form - Page 1 i - t� <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board _ .- _ _ . <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- � � _ ~-� - �Q ,Inspection Type (Fill one) <br /> Site Suffix: J ) `j ;;7 C ) Routine Re-inspection Q Q P Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> Physical Address - \ <br /> lA 1 t. <br /> Street <br /> Inspection Date <br /> City— State ZIPCode Time In Time Out <br /> Business Rep Title II 0 AM 0 AM <br /> --J 0 PM ' 0 PM REN, Operational Status i � t Business Rolete ��"r rr <br /> (Fill one only) _ � ( (Fill all that apply) <br /> Q Active r � n Q Generator �,CtoL)t�r) (; <br /> O Q Closed <br /> GPS <br /> TE Hauler <br /> Q <br /> `. <br /> Inactive h + 9 ��a °aM°✓ r <br /> LongitudeT eQ Planned <br /> � <br /> 22 <br /> .. ... i,... ,�.....,. .ENrr. ?r.�..�..._.v,. <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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING ANDr MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> compliance,Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 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 p 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 Generator <br /> Q Q Other: § In�Compiiance - No Violations <br /> Comments -- <br /> sk� ��ir�r�� � Gw a '"u ,�+�' � ''+"r �»�` �,'� ✓ � ,ri. � r�F °'b °���°°°:< � �"t3 w,� �,' • � r " °F�� f�"'�, <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � � , , �_ 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />