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4b
<br /> Waste Tire Suy $t InspectionRepor Inspection— Report Number
<br /> -- -- ----
<br /> �77ry -._.... _.-_
<br /> State of California
<br /> CIWMB 181 New 04/04) �/'
<br /> California Integrated Waste Management Board Survey Form Page 1 p _-f. 10 1 3. —T 1 „5 !
<br /> Part A Survey BLUE OR BLACK INK PEN
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<br /> � +Sle'� _.5,.1.;.ra�'+, .i,r :., ! InSpeCtfO . 7�" �L'�41j�'ui� �r.r,� ``i—.'�'j'r � '' ✓,,,"�'°kr w^r� p 'rM�trYhi,��rrM,t
<br /> TPID- 1h n r' Inspection Type (Fill one)
<br /> Site Suffix:
<br /> Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local tj ) If Referral,choose referral type(Fill one)
<br /> Identifier: L
<br /> „ "�,Vt 3>-� ��� 1 �+ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name
<br /> ` Inspected By Inspector
<br /> Physical AddressIA
<br /> I— 'rt -
<br /> Street
<br /> Inspection Date f / / E2 Lpt
<br /> <_
<br /> City Stale ZIP Code Time In Time Out
<br /> Business Rep Title ff — Q AM Q AM ZT
<br /> PM @,PM
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<br /> /I Operational Statu�.,"�i 4 C� )r � Business Role
<br /> f l r (Fill one only) ) (�W° ) (Fill all that apply) r M
<br /> t� Active Q Generator
<br /> -j O
<br /> GPS Latitude ig 0 Closed
<br /> t
<br /> 0 Inactive 0 Hauler °�4 Nr �''r �r r�/✓
<br /> ���"�r'Up� � � ak)�
<br /> � w n„77yi r r /r 7 k r f ?1l{In Yrs ter p i f
<br /> Longitude 0 Planned y fir, 0 End
<br /> ..
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<br /> =�i �'����,�`l, 'w� � ,�irr"��'
<br /> 0 New Tire Dealer 0 Auto Repair Trucking Fleet 0 Government 4 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 /> 0 Notice Of Violation 0 Extension
<br /> 0 I 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
<br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m
<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 Q 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 -Manifesf'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
<br /> 7/ ti� V'JC1 h b f al'o Lo(;r;G{t. ✓'1r .1 pr� 11. -`1 J� ',t-IC_ t'_JY� /
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<br /> — r(?C L-(A0 _ n
<br /> Inspection•Form Included:0
<br /> Comments Included: 0 -
<br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number
<br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X /;, \/ t._ ;x;i q L. L� .�
<br /> -62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■
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