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;;k Waste Tire Su & Inspection Report� pection Report Number-_ <br /> ;lag <br /> State of California Survey Form Page 1 1 2 - 10 0 6 7 9_8 <br /> CIWMB 181(New 04/04) � ('� <br /> California Integrated Waste Management Board `�" - -. <br /> Part A Survey BLUE OR BLACK INK PEN <br /> Ilk <br /> k"�'a" n^�,y: <br /> . r " �M, � <br /> .. „ r ,G,a <br /> TPID_ ' � � �� / ,,j _ � � Inspection Type (Fill one) <br /> Site Suffix: c' } & Routine O Re-inspection O Referral O Observation <br /> Local f� i -- ``� i If Referral,choose referral type(Fill one) <br /> Identifier: f{' [( 'fi'?L{-l.ys L i fq -( O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector it <br /> Physical Address LlLet—d <br /> , J <br /> r C- <br /> PA � _5 Inspection Date <br /> State ZlPCode Time In Time Out <br /> Business Rep Title _ ® AM ®AM <br /> O PM � / tf� _7 QPM <br /> Operational Status l y / «) �, Business Role <br /> (Fill one only) F� (Fill all that apply) w <br /> Active �( Generator <br /> r°hr a rti r"y „ " O End Us <br /> e iG <br /> /O Closed <br /> PSLatitude O Inactive OHauler <br /> gitunde O Planned � <br /> s � <br /> O New TireDealer QAuto Repair O Trucking Fleet � 0 Government <br /> ORRettrre;,aGMd�qheMF G'r O Dimsm�,M4�Yr e`arr^r,�rGnrs,t�l�e�r�$ T�i,lr,GwMe ✓ie�r ive1��d GeFrSr{!u�Ae <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULLNG AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> b- <br /> m -m m <br /> CCR§.18459.1 (a)(b)(c) Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV orEXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O 1 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> +`w 1% i'[ ,f , f`Vi t t, 4 o I r 1 f i {-' 1 l i <br /> tri_ { `,Lk 1. r ( �. ( f'lr��ti�I� N ofd c <br /> I r k, tlI''r i ar-C ha-,7 P(CA rI. Nork t 0 VJI r"okt V-6,4 Ti✓-e 'o'E <br /> dire TL ►'f :?{ 11 W<t t,<, -1t+/r� <br /> E ' <br /> L( D I , Z llf`i �,; Vr -� 1e k.L C. r o d :}Z< :`l t .'r r I�``_:l,4- <br /> —_ — <br /> ,+JGAN 'Af..y� <br /> S + yG„ r� t. M `�"" ,1... t~ yaia �r-.—."".. wG ,r�v✓ r r ,a.,,,s,* ",ti.:M ^,# r 'r �" <br /> �M1Yw•Gara'. '"" G:,, M <br /> h Rk GG r � , r lG � ttui'�:Bus(hesS'Rep�$Irgfl�tttAr .V�Mw�a�+v,r��h�P Qf' Ins�pe ^$+ �'! ♦�4u r,„ q� rr � ` 'I1 <br /> INSTRUCTIONS ON BACK Correct Incorrect: "A I^ 62081 <br /> Y — e. ..._...,..6.........._...w_..,....�........................__.. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />