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action Report Number <br /> El Waste Tire Su&y Inspection Report! In <br /> '-' I State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 1 10 2 56 7 0 <br /> i <br /> California Integrated Waste Management Board <br /> Part A- Surve12 <br /> BLUE OR BLACK INK PEN 9 <br /> MIN <br /> TPID- t f f T Inspection Type (Fill one) <br /> y' Site Suffix: - <br /> %` V ® Routine Q Re-inspection Q Referral O Observation <br /> Local ( <br /> _ /� If Referral,choose referral type(Fill one) <br /> Identifier. 1 i�� 'fit IL ` iC,'•VA l l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address es CE - ' ' _j e /1 1 C1 Z_ <br /> I j /yf <br /> Street O J / 7 / <br /> r Inspection Date C� D <br /> I �ICrtl � � <br /> r <br /> City State ZIP Code Time In _ Time Out <br /> Business Rep Title O AM AM <br /> O PM C� �}_ O PM <br /> a- perational Status ��' r'T Business Role <br /> (Fill one only) yr � 1 (Fill all that apply) <br /> rtjrpt p (tryhr"pb <br /> ' ® Active �; � (D Generator <br /> O + m <br /> Latitude Closedr " ';', �'9"vr t r ✓ � , <br /> GPS awe Via+ r; Q Hauler <br /> O Inactive ) �s° �� 4 Yi�1 t°yri <br /> p <br /> Longitude O Planned ' O End Use t arrr;� <br /> ..* q ._ - a Y"-�"u:+ " "m`�' yti .�a q immug azn'�i" +3k i- ✓ ;"ir '+" „. <br /> a,: r t't. :ur. m, y 4 ,ri.,o. r ,r... wi •,.', a a 'g q <br /> BUSiTkE'SS //;li t h 1 �� r /As Y w7 M1 YM .ew Jrn�i ebat 1+M a d, r tiYr +;t„ in <br /> ���+'c-'-..�,._�rd�"✓"�m�.,'�',�:��. �4 a.�''Y:,,_Y,�rY'.,..�..x-:.„�.�"4 ?'��r.:.��.lr"3„.k.fv����..�i,1y: .„rw...�.:�vr.�..,v.we�+.i �1 <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet O Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder (a Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation Q Extension <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. i Compliance Deadline <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with MMnifesting Requirements Date / <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m <br /> (Required for NOV or EXT) <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days + <br /> 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 O Other: § <br /> Comments <br /> CV _ <br /> t ! <br /> 1/ % <br /> J ,. <br /> 1(r•-I { lir Ctrr,� j t � I; N°fie.; addrPSS <br /> ed of _(. ;f ()! �” 't I >I �_ t corr�c� IOVI <br /> INSTRUCTIONS ON;BACK Correct; In�o'rlect- P 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator- _ Pink Copy:LEA <br />