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`r Waste Tire Su <br /> :., y & Inspection Report nspection Report Number <br /> a' `■ �Lb.s3. State of California <br /> ■rT79 CIWMB 181(New 04/04) Survey Form - Page 1 - Q 3 87 <br /> California Integrated Waste Management Board J g ------- --- -- . --- - <br /> Part A Survey <br /> BLUE <br /> OR BLACK INK PEN <br /> Lir „- <br /> �t�r lle . Inspection Details - <br /> inspection Type (Fill one)- <br /> Site Suffix: 1 1 ( L? Q' Routine Q Re-inspection Q Referral Q Observation <br /> Localr3 If Referral,choose referral type(Fill one) <br /> Identifier: ;1.r'1 l OCA r�- 4�Lt _-J�' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> t. P <br /> Physical Addr ssVa — 1 ✓ �'`s 1 ', t .( .{ c_ <br />, <br /> �,l� �/y <br /> Street <br /> Inspection Date <br /> City ^� State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 7 <br /> — --� , O PM O AM <br /> ' r O PM <br /> ,fit ,r1 P I _' r V ICf (w <br /> rr : Operational Status Tire Type Business Role Storage Type <br /> iire Count(Whol /PTE PF, (Fill one only) (Fill all that app �y (Fill all that apply) (Fill all that apply)', <br /> (0 Active Q Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude — F � O Q Planned Q OTR Q End-Use Q Container <br /> , <br /> Business Type (Fill all that apply) <br /> (3 New New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS P Q Notice Of Violation Q Extension <br /> Q Q PRC 42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 PRC§42956-Registration/Decal in Vehicle <br /> Q 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 /> Q Q 1 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <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 Q In Compliance - No Violations <br /> Q Q Other: § - <br /> Comments <br /> 'il ,� :�il �' -I"' 171 (l �, ..•t E , V+. ) f (-'L' ter' s'xl ;rte {�ro�_ :%+ ( /� �. <br /> ` f V 1 <br /> L... V 001 vv ec,k <br /> i ��/1 �. e `�� L/ �(.J�lrt. t L+Oki S. ._NO, Vl ~.J�'(r`• �LV (-� � CSL-��. I l;�t� ./ ( (_4�_� <br /> Inspection Form Included: Q <br /> Comments Included: Q _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X V. I. <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />