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Waste Tire Sufty & Inspection Reportlnspection Report Number <br /> State of California A ' Py <br /> ' ° CIWMB181(New 04/04) SurveyForm - Paige 1 1 6 - � Q 13 J L 4 <br /> California Integrated Waste Management Board J -- ------ - - --- ---- ------ <br /> Part A Survey BLUE OR BLACK INK PEN <br /> w a d r r1 E, � t <br /> ► ���__ �, r:.:�5 ., .r�,�,t , )M ""� ,.� �8u'�yr� <br /> TPID Inspection Type (Fill one) <br /> Site Suffix: fl, IJ Routine 0 Re-inspection 0 Referf"al 0 Observation <br /> "Local � � �.— If Referral,choose referral type(Fill one) <br /> Identifiers `,41 +, (Jird ' �t t ;, - 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit Q Other <br /> —v S___,_ <br /> Business or Facility Name } <br /> -� Inspected By Inspector <br /> _ _. <br /> Physical-Address L <br /> 1 j <br /> Street <br /> r• �, � Inspection DateLd <br /> i Time In Time Out <br /> City State ZIP Code <br /> Business Rep TitleO AM Ev <br /> 0 AM <br /> (4PM / ✓ 0 �jPM <br /> _�I i' <br /> Operational Status w Business Role <br /> (Fill one only) r (I)a)f'Ik' )�? (Fill all that apply) ,tj( �lt(at ap ) <br /> ✓ <br /> Active ES " Q Generator f7d {tl'dt } <br /> a <br /> 0 0 Closed <br /> LatitudeEE �H r i a F <br /> CIPS t 0 Hauleril"I�fn " <br /> -__I= <br /> 0 inactive <br /> O w 't rn �t k�yre` <br /> Longitude — 0 � (� ) wM"2� 0 End Use <br /> 9 Planned � r � ( �� <br /> r�rv�hwww rrtwth}� '� i �a�dCrY+"��ria<T <br /> v <br /> ,r v�(� r�-w i" r x /r Il:. i <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 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 /> 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 Date <br /> 00 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 /> 0 014 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 I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance No Violations <br /> 0 Other: <br /> Comments !! / <br /> ` JiC <br /> '� ,>r '"r C' t _ r � 1 � ( J <br /> r <br /> 1t -4 ytJ�1.(i (P ,. Jot 1f�, _{;( r,j� �j ��.:� kv1" ;Jr�_J <br /> r'1 <br /> �. v� <br /> �_ i ��t1 <br /> Yekde 0 iC� Qin <br /> INSTRUCTIONS ON BACK `Correct: Incorrect. X I ' 62Q81 <br /> White._ i� S <br /> ■ Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 3 <br />