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■ °mS° l`�= Waste Tire Sufty & Inspection ReporInspection Report Number <br /> �7 State of California V <br /> CIWMB 181 New 04/04) Survey Form - Page 1 ; 1 0 2 5 7 0 0 <br /> California Integrated Waste Management Board ---- ------ ---- - - <br /> Part A Survey, BLUE OR BLACK INK PEN <br /> all 1: <br /> spection Dd'i}Sr <br /> TPID � Inspection Typem(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Address <br /> Physical <br /> yEl. % I i 1 .t ISLA I <br /> i u V"/ ti+U., V✓ <br /> Street <br /> / Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title : m O PM m 0 PM <br /> it -------J L— IL I� f "i Business Role <br /> Operational Status mfg r <br /> / (Fill one only) � (Fill all that apply) � r14; Yi �1 <br /> MENNIM JL <br /> �a" "�5, <br /> Active itirsr �' � a Generator <br /> tirw�r,,: �6 1ti'a "k'�'4r, 'j r'a"flY aaf0i vMaSarrp w^i*a m'1 rtwr� <br /> O m Closed <br /> Latitude v' r1wP r�a�Y <br /> aarHtir O HaulerGPS 00 Inactive w r" P ��m"Y,rr Iufokf r,�lladl)rEtr�r waf�n�+a <br /> "au <br /> ti <br /> ti <br /> 7 <br /> – PlannedIR <br /> a4 go I End-Use <br /> Longitude <br /> WIN,, .rb n, <br /> O New-i-ire Dealer Q Auto Repair ® Trucking Fleet Q Government O Retreader Q Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer O Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> 0 Service Station O Hauler O Agriculture Q Shredder Q Other <br /> PaV rtInspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT-STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements <br /> Date'm /;m m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> I <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years -- — - <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities ---------- <br /> _ _O0 <br /> O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> O Q Other: - <br /> Comments <br /> j <br /> /,.-.a - - - - <br /> /* <br /> �'M . r t 4., y ✓a;f; "w r'!- f tia,r r'.^a r ti*u x�'.,'a"fat>Y""1}r X47 a, rr"'� ,a trti• �'' �, ", °`'f �"y. ,' / M.� p„"t a µi <br /> r� ��r r � a�a�"1ra a r � /I A` r.«• . s ': V 3 <br /> INSTRUCTIONS ON BACK Correct:* 'Incorrect: \/ <<' �/ LL P 1 3 62081 <br /> White' -- ■ <br /> ® Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />