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Waste Tire Sufey & Inspection Repor -Inspection Report Number <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 - 0 2 5 6 2 9 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br />` Part A Survey <br /> 4 <br /> 2 <br /> TPID- Inspection t �/ - Inspection Type (Fill one) <br /> Site Suffix: ' `_j �' G> (0 Routine Q Re-inspection Q Referral Q Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: 50.1/1 J01- t r I (� �I In 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> l b1 long L�1_trt C-oyYi I t 1 .6Pr I f U") irf 61PY1 I � �., ToTi <br /> Physical Address - <br /> III <br /> Street — Inspection Date EqN <br /> City State ZIP Code Time In_ Time Out <br /> Business Rep Title 0 AM AM <br /> l _ <br /> O PM 0 PM <br /> Looc( AMecI(tuclt� _— <br /> w1 gii 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 /> Tire Coun__ I <br /> ® Active 0 Passenger Generator Outdoor <br /> - O <br /> GPS Latitude 0 Closed 0 Altered� . Q Hauler 0 indoor <br /> 0Inactive 0Truck <br /> Longitude 0 Planned 0 OTR <br /> 0 End-Use 0 Container <br /> Business Type (Fiji all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet Q 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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> it r A HAULING AICD MANIFEST REQUIREMENTS <br /> 'Q Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 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 O - - <br /> 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 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: - <br /> Comments <br /> nlptY1GlYiIFI ;j ; ��daI�;AI k �T r(11P' 0 I l Chao. 2�'�li 41lG )5- ifs : �l�u��� OV}fL _'ff ✓ _01 <br /> r,t �an �G �IiY1 © a,•+�t ,4JjC.-1A/arK5 OISID HI421dOY1 , T0� pr M rp -- res, <br /> �e9 i to rP d or ex e m i YJau I etr'- N COk 1 9&2 gvid use. of Wosie-ire Al o n;f"t <br /> --- -- --- <br /> Inspection Forth Included: 0' <br /> Comments Included: <br /> 0'Business Rep's Signature Phone Number Inspector's Signature -- Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X 1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> a <br />