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Waste Tire Sur6y & Inspection Report Inspection Report Number <br /> L° State of California <br /> for ° Survey Form - Page 1 t 3 . 10 1 0 5 2 0 <br /> ^: CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board -. .. ... --.. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business ProfileInspection Details <br />} TPID_ Inspection Type (Fill one) <br /> j r ` - <br /> J j ' I - 6 Routine 0 Re-inspection 0 Referral 00 <br /> Site Suffix: bservation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name (, - Inspected By Inspector <br /> to <br /> Physical Address <br /> i ELLI a �" <br /> Street <br /> Inspection <br /> t ection Date <br /> City f State ZlP Code Time InTime Out <br /> Business Rep Title AM 0 AM <br /> 0 PM O PM <br /> II <br /> I � — <br /> Operational Status i ,t ` Business Role <br /> ` (Fill one RRIJ l (Fill all that apply) <br /> Tire Count(Whole/PTE) � nw <br /> �t,� rr) <br /> 0 Active �° tlige z e Generator <br /> ¢y, u � rr raw rI ��^ r9vti��raM1+ r <br /> 0 Closed <br /> PSLatitudeGwrr rw ;t°xl�e�rrt3�i O HaulerE — <br /> l� <br /> e <br /> �i rw ,� , <br /> ® Inactive LY C�:ty,t ; rr>� i <br /> O <br /> 0End-U: <br /> snrd ULon itufde <br /> 0anne <br /> ¢z <br /> ; <br /> rs r rvr <br /> 103d.,i.Naw,Y w,ef"M.�Hr.dID.�o� ,� #✓'m.��e e�I,�✓'�>."""dQ�.:��.�.�r� �S,::...''r�.1�.y�.Au�"' Ca.i'��^,r;aua ,r..� a,� +� _ <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 ATire Derived Fuel l <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 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 /> 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 Date m / 0 / m <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 <br /> (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 /> O 0 § vRequirements - - <br /> 14 CCR 18461 -Manifest System 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 Y ` <br /> Inspection Form Included: 0 <br /> Comments included: 0 <' <br /> Business Rep's Signature Phone Number Inspector°s Signature Phone Number <br /> ® 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: r�..INr,r="y L j L a � i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />