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Ins ection Report Number <br /> Waste Tire Sury & Inspection Report p - _ - _ p_ - - <br /> aati7 State of California <br /> #®# # JCIWMB181(New 04/04) Survey Form - Page 1 3 ^ 10 5 0 0 8 <br /> California Integrated Waste Management Board — ---- -------- — <br /> Part A- Survey ,.BLUE OR BLACK INK PEN <br /> B`UStt1iM _ »' '.�` 1 ;r.gm­ <br /> �ka � <br /> TPID- Q' / Inspection Type (Fill one) <br />} Site Suffix: T-313i 19S�(.7 � � ( I Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 9991" -? ,: / 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name r <br /> Inspected By Inspector <br /> Physical Address <br /> t I? <br /> �(- >ll; LP <br /> Street ;7 Inspection Date <br /> City State . ZIP Code Time In /Time Out <br /> Business Rep Title ' O AM <br /> . � AM <br /> �� O PM ! QPM <br /> ( __ _.__ <br /> ( 2 1 <br /> ,b; Operational Status Tire Type Business Role Storage Type <br /> "diree�t8nt�W1D9e/PTE (Fill one only) (Fill all thatapply), (Fill all that apply) (Fill all that apply) <br /> 767`7 �Active 0 Passengel4 Q Generator 0 Outdoor <br /> PsLatitude _�. O 0 Closed D Altered <br /> G <br /> o <br /> Hauler Indoor <br /> Inactive <br /> �0 <br /> Longitude — 0 Planned OTR 0 End-Use 0 Container <br /> Bu�ln�� <br /> C New Tire Dealer 0 Auto Repair ® 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 0 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 <br /> FTm 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 (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 i CIWMB Enforcement <br /> 0 0 § Y q - <br /> 14 CCR 18461 -Manifest System Requirements for Waste Tire End-Use Facilities I -- <br /> 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 /> i I <br /> ti <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:9 Incorrect: X "- <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ` , ■ <br />