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Waste Tire Sur & Inspection Report �3pection Report Number <br /> - - <br /> State of California }J'`�y y� �Jj <br /> CIWMB181 <br /> Waste <br /> eMana14) Survey Form - Page 1 V 0- 0 V f O 5 <br /> California Integrated Waste Management Board " <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> If I�Ispr�� l�rtt i"�eE�ltls <br /> t <br /> TPID- Inspection 7 Inspection Type (Fill one) <br /> Site Suffix: I f o 0 0 Routine 0 Re-inspection 0 Referral 0 Observation W <br /> Localo If Referral,choose referral type(Fill one) <br /> Identifier: `i . (;r`l rl (,.r lr L t + 'I_ `( ;+ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> � Inspected By _ Inspector <br /> Physical Address r`T <br /> It I <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ® PM ELI- ' 0 PM <br /> tori. �� t�� f ,tf c4y. i 1. sa <br /> Operational Status , Business Role yt <br /> (Fill one only) (Fill all that apply) <br /> _ k*r ��' e ✓"h a ,��1�'oi"bra rr, <br /> - Active ) (D Generator <br /> _T7T__7 <br /> f�� � r�r' 3 � i t✓i to <br /> e ,r r r r✓t aatlr <br /> LatltUde Closed w a f r fur{, r y sf r rd�r ` <br /> is Irks <br /> GPS �nG�aw4t �^if Q Hauler f � � ) K <br /> "9 �1 ��o✓��r" �r Ci r rr r <br /> 0 Inactive ��,� > " wY,,✓ a � <br /> r O '1 .'dyVtdM r t r+,"�.°a "reti9wfi�^ 1r r <br /> Longitude0 End Use <br /> 0 Planned I f <br /> `a <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 I0 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 /> 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 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/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 <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> " (/�t iv t: C !(Ji'S IAJ0 r"/' -�F <br /> -t�`ti� x `' �V1 �.E '6 (.� I`C(1 �# � 1c1 c t ✓�_'/ t_�JjJrl l �:t(�Cit� /� ri� (•:;ctC� <br /> at ( Cd, c t P).. I /. ('' 04('.( c t 1 1�(.4 <br /> 1�/? � ( (' C,(-L II'/1.f, f (,C,C'' -�I(>'" / �1 � ({ { ( 0r'i :i LuCa' /(. _ �i�C C�It if <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X/P _/ ,� 1 2 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />