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■ e <br /> _ Waste Tire S y & Inspection Repo rinspection Report Number <br /> �� _ - _ <br /> �.i State California Survey Form - Page 1 <br /> = CIWMBB 181(New`44/04) <br /> California Integrated Waste Management Board ' <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> a�rv, ' Y 7 ..y�y ,�.i1, yr�y�rr��"v,I, !r „w l ' w• r r " r �rda1Y� s <br /> eu• JR >''�r(d(' �t i+e.., 'ff,�r�r��7��. <br /> TPID- /`� Inspection Type (Fill one) <br /> Site Suffix: r r k/ / 9 - 4l ® Routine Q Re inspection Q Referral 0 Observation <br /> Local ^• y- If Referral,choose referral type(Fill one) <br /> Identifier: �j / t' i-i(L j f i'L(rl..�' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> _ f -_4-­_1 <br /> r , <br /> 7 l <br /> Physical,Address t <br /> Street <br /> Inspection Date <br /> City i State ZIP Code Time In _ Time Out <br /> Business Rep P l Title - PM <br /> [�j <br /> O PM <br /> = 0 AM <br /> ir(_Vt{YI %" �.;L" t I t. I ) .:- 4 I f iBusiness Role Stora e Type <br /> Operational Status Tire Type .......�, ` g yp <br /> (Fill one only <br /> (Fill all that apply (Fill all that apply) (Fill all that apply) <br /> 1 6 Active 0 Passenger 0 Generator 0 Outdoor <br /> D 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> . - 0 Inactive 0 Truck <br /> - <br /> Longitude — 0 Planned 0OTR End Use 0 <br /> Container <br /> �� .. . <br /> [7-T <br /> ?3€ssirs+es `I ype (Pili 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 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> - <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 m / 0 <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 (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 /> Comments <br /> FDS r( ►'%GPIs! l,, �.,, ; fir,,.. ��,:�. i�r lr) r' n`��t j `fir<tr !-Ao u"a'( t�;r `` <br /> �� � <br /> (>1( `' y ; {oi.( c ) OpyjF6I �.%Y' (:'CrLi '�.� , `.t's' 't `{ ( VIC <br /> Inspection Form Included: 0 <br /> Comments Included: 0 Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 8y L E _-.. L <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />