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Waste Tire Si Icy & Inspection ReportInspection Report Number <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 4 10 13 7 5 5 <br /> California Integrated Waste Management Board L 1 <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Ram <br /> # <br /> F <br /> TPID- d 10 KI Inspection Type (Fill one) 0 Referral <br /> Site Suffix: Routine 0 Re-inspection 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: jorA q.,U 'I -11AL K I <br /> U. 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical AddressJ <br /> Vj <br /> Street <br /> CA <br /> Inspection Date <br /> [�H / <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title AM AM <br /> ✓ J r 0 PM <br /> DEC]) : ER,-J, 111ii] [Y�2 <br /> Operational Status Business Role 0Q <br /> (Fill one only) (Fill all that apply) <br /> Active Generator <br /> 0 0 Closed <br /> Latitude <br /> GPS 0 Hauler <br /> 0 inactive <br /> Longitudea as <br /> 0 New Tire Dealer 0 Auto Repair (3 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension 1 <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <br /> 14 <br /> 0 0 14 CCR§18459.1 (a)(b) (c)-The Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> ------—------ <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ---------- ——--------------- <br /> 7, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> (5) In Compliance �-,,Nct Vlolpttion <br /> 0 0 Other: § <br /> Comments <br /> f-L <br /> fo <br /> o[ obCki 410 N(kc,_ I i/I <br /> V)i'l C(z; a <br /> I. IJ Vievurdtt, 10o"Jo 1(e Wt A <br /> Ml,-Y (OV1, I/od �.'Jtj's <br /> ,p ",7.n ✓ ,n rlow" <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: M P 62081 <br /> L <br /> ■ White Copy:ClWM13 Yellow Copy:Operator Pink Copy:LEA <br />