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Waste Tire S y & Inspection Report Inspection Report Number ■ <br /> California State California i <br /> a� CIWMBB 181(New 04/04) Survey Form - Page 1 ` 1_ 9 -- 10 1 0 „5 8 _ <br /> is Integrated Waste Management Board + <br /> Part A- Sg a BLUE OR BLACK INK PEN <br /> tl .P'ul,�lrr�t4, `' i` "'. 'a'r�k 'ta% v "��'^ + <br /> �.5.�6• ~"ri�5,.- �'�,k9 •: ...'._."_�.. <br /> Site - [ 'Inspection Type (Fill one) <br /> Site Suffix: <br /> ry -� ✓ ( Q Routine Q Re-inspection Q Referral Q Observation <br /> Local f If Referral,choose referral type(Fill one) <br /> Identifier: `,k f +; t" I'T, O CHP O CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name i f' <br /> Inspected By Inspector <br /> Physical Address j / � j I <br /> Street <br /> + i Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title <br /> q 0 A II , OAM <br /> �i?:,. O PM �J O PM <br /> Role <br /> in <br /> Bu <br /> Operational Status <br /> Business oe <br /> W WN <br /> Y ^ a r Y a <br /> Tire Count (Whole/PTE) 1(Fill one only) (3�� �^ (Fill all that aPPIY) <br /> r„ ^ a <br /> ^s -: � Active �, ' twp ® Generator <br /> �l J Na' 4'dr Aw'✓� t'Yd yr Yry <br /> O Closed <br /> GPS�+ Latitude <br /> td� �� 4 + O Hauler <br /> — O Inactive <br /> Longitude — " �k��( Q End-Use �` fn 1 : <br /> Planned ,•,,,r 4r r. Y"�uti.. �.�Y"h? d,>,�,d�,„G'� M w ti!a, .. <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station O Hauler 0 Agriculture O Shredder Other <br /> i <br /> � r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> --- —_ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q .PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation Q Extension � <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 ' 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days i <br /> (Required for NOV or EXT), <br /> O t 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years `` —” <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> i <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ° , V7olat71, <br /> O O Other: §, . <br /> Comments f( L; t � ( v f�C. 4✓ ��i:{ �,�_�.0 l '� ; i{;:J `;',� i ✓; <br /> ����, ( �' �:tJf r,� �" t7•-t�� ;c.r 1r..,, 1 n ; t irl :;i.,rc J IC/� .,. ��t�/r �.���•���-cy��..h �� �. �,_ . ���. <br /> ;I 't f rl<._ /!)>'1't'1 F �l C T/' k f t-�c rf - rt� �� t l:i. -1` <br /> 'i ti .{r o a r mavtiti��'? l >rrr, _ 1� c; -d r- � -{? `v �. <br /> INSTRUCTIONS ON BACK Correct:IS Incorrect. �/ ¢ 4',k,� � 112. 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />