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y p Inspection Report Number t <br /> ® Waste Tire Su & Ins ection Re ori __ p _ _p _-_ _ - <br /> "' State of California T <br /> CIWMB181(New04/04) Survey Form - Page 1 1 11 10 2 5 0"11 3 4 <br /> California Integrated Waste Management Board --- ----- - - <br /> Part A�� Survey BLUE OR BLACK INK PEN <br /> *,nn <br /> Site Su - Inspection Type (Fill one) <br /> ffix: <br /> TPID- C •; i � r � <br /> I i t/ d"Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ; . If Referral,choose referral type(Fill one) <br /> Identifier: r: t,�� t C .V s, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> A• r ' <br /> Physical Address <br /> Street Inspection Date !t <br /> Cite 5tafe 2!P Code Time In Time Out <br /> B7_1 0 PM 0 PM <br /> usiness Rep Title O AM O AM <br /> I <br /> 0,v., <br /> „, ; Operational Status T w P Business Role <br /> (� (Fill one only) (Fill all that apply) f(�i,�, ��' �', <br /> Active "P4t1' Q Generator <br /> O <br /> 0 Closed <br /> GPS Latitude _�� . �� 0 Hauler <br /> 0 Inactive <br /> O r�r t E r leaa cwt rrN; nm �� <br /> 0 End-Use <br /> Lonitude Planned <br /> "; 'f:�• r'::,5diii�;�r it MrrHx: r r' n x:"� rYp" +xr y,+'ti r�>+,,�' t i � u� fM; r f�y <br /> �",+ <br /> r ✓d r r � � .'s � ::.e '� at yr� � a �,.Rnn "a + � `� u�m.�' r ��_� ., ",�1r�'ru v'.�L z�r <br /> i@ New Tire Dealer DW Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler Tire Derived Fuel <br /> Q 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 !— - ° <br /> 10 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 40 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Ffl / FTI' / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB j <br /> 0 I 0 (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 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 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> IF <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators d " ° ��r J".>rr"" <br /> 0 Other: § / 1 r ;_•� <br /> Comments vJ.1 <br /> 1.4 r <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> 0 Business Rep's Signature Phone Number Inspectors Stgnature Phone,Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X E' <br /> L t-FTI 62081 <br /> LE <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA S <br />