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Waste Tire S & Inspection Reporpection Report Number ■ <br /> State"s � a CIWMB <br /> f 81(Nrnia Survey Form - Page 1 I 1 7 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board ------- ----•-— - -. - - ------- ----- <br /> Part A Surve F BLUE OR BLACK INK PEN <br /> w drf { -- <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: jt:; , . I1t i i i t_ <br /> ' � i,_ O CHP Q CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Tel <br /> Physical Address - - <br /> U <br /> Street Inspection Date j EE( / [ju .) <br /> City State J ZIP Code Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> L�1�_J —1 0 PM DOE 0 ® PM <br /> 64 f I LAy <br /> J Operational Status <br /> Business Role <br /> NEI <br /> (Fill <br /> oleI (Fill one only) (Fill all that apply)) <br /> -7 ® Active ® Generatorr <br /> O Closed <br /> GPS LatitudeEM Hauler <br /> 0 Inactive <br /> End-UseLongitude Planned <br /> �Eo 0 <br /> 11111111;i;11111111111111=111 11 ligiffigilligilli BIMINI I i1a 111 111 <br /> IMIIIIIIIIIIIIIIII <br /> , <br /> �.. <br /> a. <br /> 10 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber -Ty 'll - `` <br /> / `J <br /> O Service Station Q Hauler O Agriculture Q Shredder (S Other (L) 'r r /t tvt;;} C"rU <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> l <br /> Q Notice Of Violation Q Extension <br /> O 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O <br /> 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 <br /> O Q (Other: § (( { <br /> Comments _I c_ f t G� �obi n k. r� E I l?v�(yl['^ yi G a 4i of-,, C�° "( <br /> t' N <br /> g + <br /> (tri I '� '�! rJr U '[ .triC.l Q13j1 i r✓ UI`: t;c� -'�-� (u C k � �t ct u� u0",f' f�r <br /> oVer `IL's /Ut C Cd✓3r-� t/a''�kfC>.f�1 '--UiJ t - <br /> :.� Or) r �({?/ },l:;ti ✓):^�L a.-� V.)pI1 Ir fj=Ff(z t / ' 4� r,4- Irl ttYviIi✓�< !sem) <br /> Iq <br /> J , } <br /> InSpectt 1'tti�`Cl �"• IL r 'r w,d,, rtt a w rr ,l <br /> +�#���� � "+���z � rt tr '"^� r y'-P � � � ^` ��"�'pf� T !„�., Y^" �, � f, �,� r t q�. � f✓' 4 <br /> Cb�nter�i x„ r Nt1 w µ uk ,-,: <br /> 9f�nattrre', }�,��� „ At�"�. . " �'��,r..�,,�n�t?._t�r's.Si <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X l V ' ,A r�i P 1, t c 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />