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■ : . Waste Tire SL*ey'.& Inspection Repo )spection Report Number <br /> teas - - - - <br /> �$® � ClWM f 181(New <br /> Survey Form - Page 1 - i 3 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A Survey BLUE OR BLACK INK PEN <br /> l,., w ,s x ,wr' r sasrw�tt.x;fess +s w, 'r 1Es r +, Rd •yv'�, �'.,d I��'s*r «M`Nr k� ,t 'F,„'s+wr'i"�P ,cr N rr Y r %01 <br /> . *f r_ <br /> TPID- Inspection E Inspection Type (Fill one) <br /> Site Suffix: <br /> ( � 1 '✓ i' � Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local --- / If Referral,choose referral type(Fill one) <br /> i Identifier. '+i j{..!' t4 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> - <br /> Street <br /> --(// !! /L Inspection DateCv <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title Q AM <br /> f"t [= = Q AM <br /> j + r T '­J` � LTJ Q PM QPM <br /> Operational Status k ti ",r I r f Business Role p )t <br /> es <br /> (Fill one only) ,ttlI ) (Fill all that apply) <br /> Tire Count Whole/PTE I" a <br /> O'Active Q Generator t^" : tilf, �a�s1 <br /> GPS Latitude O � Hauler <br /> 0 Closedm� "" s lr1 <br /> 0 inactive� <br /> Longitude 0 Planned <br /> 0 End Use <br /> „r ys�r x,�Y�,"�"st. s,lts ✓s.:s r"7 <br /> New Tire Dealer 0 Auto Repair 0 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 Q 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 <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 <br /> Date;m /-m / m <br /> O . <br /> 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 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 /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: - <br />� Comments i , +)( Ir'J� I>s.• l / i �ti..Rt+1�-ri I:_. �r.-�p, _�!f <br /> All <br /> i;' y ``/` <br /> -- -�-- f t J i 10 <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - <br /> Business Rep's SignaturePhone Number Inspector's Signature Phone Number <br /> - <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X Gd, --F a "hr = _ 62081 <br /> i. L , <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />