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Inspection Report Number <br /> i' <br /> c <br /> Waste Tire Su4y & Inspection Report ■ <br /> Stateof <br /> 181(New 04/04)California <br /> CIWMB Surve y Form - Pae 1 i .1 - l 0 l 0 6 6 0 <br /> California Integrated Waste Management Board -- - - <br /> Part A Survey BLUE OR BLACK INK PEN <br /> MEMO <br /> MEN Oil <br /> Fli <br /> _�....x.�r vl{„,tSm.E..tl Nom. <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: _� ' F Jill Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local -- 'i If Referral,choose referral type(Fill one) <br /> Identifier: �, , , 1�(( , :� << w <br /> �c f til t't -�� 0 " 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address �I <br /> � I <br /> Street <br /> Inspection Date <br /> i me In Time Out <br /> city State ZIP Code Time _ <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> SC <br /> Operational Status Business Role r ' <br /> (Fill one only) P)"►IfII� (Fill all that apply) i wflrstt )y �,8 <br /> � ��x f r�r1 r� 'r s/r° ` � w'��i ✓,r ern r <br /> ® Active ® Generator <br /> 0 Closed y )ti��feyrp L )� r1 lr <br /> Latitude turde wr'��4wwri�i ty"�l"M�jµr"wi�wr'6�w��-1"n�r�}"�pTr�J'°���aw�„("wKM1)5Po3�'W iY)sti�?✓�!d w'"r�°r°wr>w�ahw^dzlr9 a7aur"9�r s �„. Hauler uler <br /> Inactive <br /> Longitude 0 Enid-Use 0 Planned 'GP ”Y�GIf''Prryw.(,,I°,r]„,rcttrrRyv,rrki`^(�x4g7t'•(nrR�*ag�arGrldr✓r y�iiyfrlrrri <br /> htrtr'�rcr✓,t�'��nrrprrrrc�y�M;'',�r"�. <br /> ` <br /> wda <br /> ip <br /> - <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 ® Other <br /> I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V j A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> 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 /> M / m 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 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 /> -fj(�' •� ;,A;� f� , ;I� ,�--� ` � `?!� �r—Q L- Y- <br /> ;, Wd Ve 7-�. tit? :� -L _Rlr) .�/�f�1�:� �`r t ,f� , t ol; l - <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X ji \/ .�, I <br /> � 02081 <br /> w� 1. r� <br /> ,tii� . <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />