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A. <br /> AWaste Tire Su�� by <br /> & Inspection Report' nspection Report Number <br /> ■ ■ <br /> ��@� �, State of California ( � A (jy� <br /> CIWM6181(New04/04) Surve`, Form - Page 1 I 3 - 10 <br /> Part A- Surve {, BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: CC I I �( ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ) r ' If Referral,choose referral type(Fill one) <br /> Identifier. �" [i'•'�. 1 l �a ;�- <br /> � viV }; Y, . 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> - ' B <br /> Inspected Ins <br /> P Y Inspector <br /> Physical AddiC ss <br /> Vivo- <br /> Street p � <br /> -r Ins ection Date G / [ <br /> i ) Time In Time Out <br /> City State ZIP Code _ _ <br /> Business Rep Title Q AM <br /> QPM <br /> QPM QPM <br /> �r Operational Status IT hire �ve i t� y Business Role 1" 1e, <br /> � °� (Fill one only) (Fill alfi��� (Fill all that apply) (F � ��� <br /> Tire fount(Whole/PTE) <br /> 0 Active 0P�� �° @ Generator door ' <br /> GPS Latitude O 0 Closed 0Alts„r%y' <br /> X <br /> �_1 - ��� 0 Hauler door <br /> Inactive <br /> Longitude �'- 0 Planned 0 OTR 0 End-Use 0 Container <br /> b MzwF,n° ]OW-11,911 LLL <br /> Business Type (Fill all that apply) ` <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 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 (k <br /> 0 Service Station 0 Hauler 0 Agriculture 0 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 <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 headline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date [T] <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 1 M <br /> 0 0 § <br /> Other: <br /> i <br /> Comments 4 F f�- �/ <br /> c' It-” ut <br /> _ ( r�� Cr '�!'1C� �t C� i'°✓'it.�' it ( S 1' / rc'tI c� _sF -) G.ta� <br /> V y <br /> If yl )NO <br /> . IX <br /> r t2 • r f"'� �{ ,t r ' - "�r��,��y � ��f��u"rr� �r�b H p�� " '.: <br /> �. � °• i 'fr?� 7 °�'�,.,wr� ,'1~f if z7�1ne'S'"u, ' p .,6lrl ,ttr y".n ""y d b " °" ' 1'', <br /> -` <br /> INSTRUCTIONS ON BACK (`Correct:* <br /> ■ -- Inc-orrect. ;X -=-- <br /> ` ®62081 <br /> ; p y <br /> White Copy:CIWMB <br /> ■ <br /> Yellow Copy.Operator Pink Copy:LEA <br />