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: Waste Tire SAey & Inspection Repo Inspection Report Number <br /> -_ <br /> _.- •:m State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 1 7 10 13 0 3 <br /> California Integrated Waste Management Board .�� __..-_... -_. --. ........ -i <br /> PartA Survey BLUE OR BLACK INK PEN <br /> .,s.., ,�.? i.Fr.#ucrnGv'~ .,ir�aaro?C. ,.wv. m,,.>�4 ,�,( i,tW�w•� m i _ arv,,,..�Ya.. '� A , r A � — — .—.,,)��! ,._..._.�. �� k...... ,_..,. <br /> iInspection Type (Fill one) <br /> Site Suffix: (3,-- - J _ <br /> L ( _ <br /> `� Routine O Re-inspection O Referral O Observation <br /> Local t'4 If Referral,choose referral type(Fill one) <br /> Identifier: J f.1 T: c 1 V1,. t� <br /> _y t (!I J_v 'I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name. ., Inspected By Inspector <br /> L �: ,x ;.'z' 1 JJC� In <br /> Physical Address — f �a i - <br /> L_Street <br /> Inspection Date <br /> ELL <br /> City State ZIP Cod Time n Time Out <br /> I <br /> ----- T <br /> Q AM <br /> O FM QPMBusiness Rep Title OAM <br /> Operational Status Tire Type Business Role Storage <br /> Type <br /> T&rLv d3llfA#(Ull}14i�1�/PT j" (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> JIMActive 0 Passenger <br /> a , � � •, >„�, • Q Generator 0 Outdoor <br /> LLI �D Q Closed 0 AlteredGPS Latitude EE . Q Hauler Q Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude <br /> O Planned 0 OTR Q End-Use C Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> --- - <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> Q 1 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 010 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 1 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 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 Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 1 (4) 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance No Violations <br /> 0 0 Other: §� _- <br /> Comments <br /> h <br /> 110V`t�t <'`�-� <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:16 Incorrect: X ?,"; =' l_ l.; a 1 L i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />