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r Waste Tire Suy & Inspection Repor�_ispection Report Number <br /> ■ ; tial State of California <br /> i-1 <br /> A <br /> CIWMB 181(New 04/04) Survey Form - Page 1 El 1 0.0 0 i 6 9 <br /> California Integrated Waste Management Board —'—'- -` ---- -_- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile DF:t ill <br /> W_ <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: {E ✓t _.....I Q Routine O Re-inspection Q Referral 0 Observation <br /> Local sl If Referral,choose referral type(Fill one) <br /> Identifier: { ' i- l � j rL j� t y, �� 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ' �l <br /> Inspected By Inspector <br /> Physical Address �-1 r I ���`'y1 f '•t i _� <br /> 1 <br /> Street / ( / f 5� 1'SL ' ' Inspection DateD- a-- 01 `1 <br /> City de Time In Time Out <br /> State ZIP n <br /> 0 PM <br /> DE <br /> _Business Rep Title 7l I� 0 AM O AM <br /> Operational Status Tire Type, Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> LI Active 0 Passenger Q Generator 0 Outdoor <br /> �l O Closed O Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O <br /> _ Q Inactive Q Truck <br /> Longitude - �Y-T7 . [ <br /> � 0 Planned 0 OTR 0 End-Use 0 Container 1 <br /> Business Type (Fill all that aptly) <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> O Service Station Q Hauler O 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 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date 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 0 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 f 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 O In Compliance - No Violations <br /> Q Q Other: § -- - <br /> Comments fv),�IIA i, �rlg AL;<-s Ull <br /> lQ �;'�( �1`Zy� lYl �( s`fI( {" ;r i i s - I - <br /> _ r , <br /> tai ' <br /> Inspection Form Included: a <br /> Comments Included: O _ - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X j L � I ���il r' L i 2Tf <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />