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Waste Tire Su & Inspection Re or Inspection Report Number <br /> Californiatate of California <br /> Pl A 17 .0 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 1 1 <br /> is Integrated Waste Management Board �----. - -- ---.-- ------ --.-- <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> TPID- c (,- ( � ;Inspection Type (Fill one) <br /> i Site Suffix: I ;� Ca ? V <br /> ® Routine . Q Re-inspection Q Referral Q Observation <br /> LocalIr-� If Referral,choose referral type(Fill one) <br /> Identifier: �(�Ir) �,i �.l (� tat;l-Y(� � ' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected Inspector <br /> o <br /> t y <br /> Physical AddressLAI 11 <br /> Street �r ( <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title C` <br /> if AM ? O AM <br /> �� (a PM O l7� ✓ t✓ PM <br /> Imo_( 1�� � ` a lSr� _ �t_� ,/Y1.�: •�"� - <br /> Operational Status , a Business Role <br /> , Fill one only) � Fill all that a I � <br /> e>� LaL <br /> �tI°dui. <br /> Active �,I f �( (S Generator r r r <br /> F7 0 Q ClosedQ( <br /> GPS Latitude � , OHauler <br /> Q Inactive i off" <br /> L 1r s <br /> Longitude - � Q Planned � Q End-Use <br /> business T <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> i <br /> Q Service Station Q Hauler Q Agriculture Q 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 Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 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 /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q ® 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance No Violations <br /> QQ Other: § __ " "`«�� ^': X, M ,,"✓�*, .r.;:; <br /> Comments <br /> /•vj�{_((f'.,•l I�' _rI t/i lt';J 16'i.� l �l'.j hy, /o Ovait_ j(i <br /> .l { <br /> G <br /> f 11� _ tt <br /> �(�f'` tJ �t �0 t;1t�+.1f � . ,til` '1 i p.. - Jj`�`aj(z. lur 04 <br /> i <br /> 't ►}'t� i; --f<<Q`�• 60o4p l- WivicIW p� V1 (s SII ` ir <br /> ., f f <br /> f <br /> VMI j <br /> r <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: a a�, wy 4� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © S <br />