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■ Waste Tire L' �y & Inspection Repor Inspection Report Number <br /> ` �-` State of California <br /> °�` Survey Form - Page 1 10 10 ,642 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board -._.___ _—__..___ ._.....---------_ i. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspectpf! <br /> .- . �,_.. <br /> TPID <br /> - i I I i Inspection Type (Fill one) <br /> Site <br /> f Site Suffix: { % J W Routine Q Re-inspection Q Referral 0 Observation <br /> Local `y If Referral,choose referral type(Fill one) <br /> Identifier.. : ;j 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> ,- <br /> l d v i T <br /> i <br /> Physical Address <br /> Street ' <br /> J Inspection Date / l 1 <br /> City �— State ZIP Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> —ELI _� Q PM �. Q PM <br /> Operational Status Business RoleStorage Type <br /> (Fill one only) a � (Fill all that apply) (Fill all that apply) <br /> t, Active ,' , Q Generator 0 Outdoor <br /> 0 Closed <br /> GPS LatitudeLLi 0 Inactive „� 0 Hauler 0 indoor <br /> O ( ,�A�w ' <br /> Longitude – 0 Planned i'' 0 End-Use 0 Container <br /> ..;.;.:ib Y,;' m ',xi"" 'f� l t ? ! ��( a ��p���d�� ° N�'�rit4x„ v�G-ri a �✓� w��,i u '�r�,�h(tqw rre,' ti <br /> b4 <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 6 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 /> V ' <br /> --- ---- --- 0 Notice Of Violation 0 Extension <br /> 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 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 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 )6. <br /> �1��� �' �JttE.t. .( <br /> 1 ' <br /> dr �:r V'Jr� �. i��' — J-- f v�d ki'_ <br /> . u_ <br /> r � <br /> _ ';> �" , �f` t`:`�t� it����i � �_!(>"l �U'(Yt 1 L��)E-�t�' '_ r i F. j3rr,1 `,(•'��.- `�� �',�;r i.:f <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Si-gnature Phone Number Inspector's Signature Phone Number <br /> _ _. 6208'1 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X L; j 1 i ;I <br /> ■ - ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />