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�� in Rort NumberWaste TireSuptdo& Inspection Reporaction e <br /> __-�_ _ p .. <br /> °'"`W State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 1 8 - 10 Z 5 v 8 $ <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile <br /> r�,�a 1?� etaits <br /> TPID- y (r - — Inspection Type (Fill one) <br /> Site Suffix: I ` I j ( (9 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: V- /�Q L- .��� G 6tVt{, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V Inspected By Inspector <br /> - -- <br /> Physical Address <br /> i t G� I�C✓ F J i — _ a j- <br /> Street � C , C / I(I C r <br /> •� � Inspection Date � � ' � 1 � <br /> L a <br /> t-- _ <br /> Ci!v State ZIP Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> A � 0 P QPM <br /> _N <br /> - -1,1 Operational Status Tire Type .� Business Role Storage Type <br /> (Fill one only) (Fill all that apply): (Fill all that apply) (Fill all that apply) <br /> 11`t °"`1A^ t ( (Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> .' Truck ff �O 0 Inactive D ,lack <br /> Longitude Planned OTR <br /> 0 End-Use Container <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 )C- i - n f> <br /> i r <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ��`"'Other 1 �G✓� (1��IC 1Q + t l Y t V�1 <br /> I <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 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 Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pate M / Fp / m <br /> 0 0 14 CCR§18459.1 (a)(b) (c)-Tire Program ID Number from CIWMB �''w <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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Commentsr <br /> t 1;-4 P Vy1f,�"dn Wii.y 710;e,7, 10 YPd1tJV£ -P lQcfd.'_ cir'1G1 <br /> Ui��l �Q. tt /P /Y�•'JO`l�`� VIRA)(14 Lklo- t MCSf9r 10 <br /> 1��(i�;�C f L( :_'t✓4? �1 vr` <br /> f <br /> Inspection Form Included: 0' <br /> Comments Included: Or <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X , <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />