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ction Report Number <br /> Waste Tire Su9y & Inspection Repor _ Inspe ■ <br /> - - <br /> State <br /> u'Z <br /> CIWMB <br /> f81(Nrnia Survey Form Page 1 - - - 0 . <br /> CIWMB 181(New 04/04) � � I <br /> California Integrated Waste Management Board _. -. <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: J Y 7 7 � 7 � t/ ® Routine O Re-inspection O Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. j C y /!. r .. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U _ - - <br /> Inspected By Inspector <br /> Physical Address <br /> Street '`7 <br /> Inspection Date / / `r / ' <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title <br /> � AM <br /> ��� PM QPME� � <br /> 0 AM <br /> L, u"syxrz'4°fN' - - -- --- � <br /> Operational Status i, I r i' r Business Role x <br /> (Fill one only) (Fill all that apply) �I�I 1 <br /> rYr�r,�Y� Yt` lr tt ar r <br /> ® Active y + ® Generator <br /> O I Q �� w +r1ri <br /> Latitude <br /> GP$ O Closed0 Hauler <br /> +r1at <br /> — Inactive <br /> O <br /> tr �rYLY,r i <br /> Longitude Q End-Use <br /> Lon <br /> 9 Q Planned <br /> r•'' ^ir�' ,,; r+,�P „ Aar�.z H ;i°�'rar'r�' ,.,/r �f.�'Nr"d w"'G r,� � r, <br /> - <br /> #, ,., ill �s �,t �r 1M +� <r. ,, r err ,t .. >'��,.,r � 1,r, , � J^'' M t 5 r» , ,Y� w ff ✓,,v <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body (@ Car Dealer Q Collection O Crumb Rubber <br /> O Service Station Q Hauler O Agriculture Q Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A j HAULING AND MANIFEST REQUIREMENTS <br /> --- - O Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q 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 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 0 0 Other: - <br /> Comments <br /> �i <br /> Phon- !n )actor S► natal a Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect I . <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />