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Report Number <br /> ReIns Inspection Waste Tire Su y & Inspection Report p _ p <br /> State of California �_- n . -- <br /> CIWMB181(New 04104) Survey Form - Page 1 >� Q 1 4 $ _ 1 <br /> California Integrated Waste Management Board <br /> Part A Survey BLUE OR BLACK INK PEN <br /> AM— - <br /> ��� rrs.� "e% ��ti .✓ L �., ,��.•r ¢4.r,�,;+� �1���Gi�� <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: _T"JT1 1 , [1 - Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: moi'- j ,. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Phys c-Address , 7 c tt <br /> Street <br /> Inspection Date ?� O EH <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> � 0P � � 0 P <br /> �hf ", Operational Status r � ��, Business Role <br /> " (Fill one only) (Fill�I (Fill all that apply) <br /> ® Active i>'�)� f GeneratorMEEK L_ _ <br /> Q Closed <br /> GPS Latitude x�+ '�� tiiQ Hauler <br /> h � d <br /> Q Inactive <br /> O <br /> Longitude Q Planned � P ` ��1t ,��;^I O End Use � ], aktalr , <br /> � +'t� <br /> +n:,;�*' <br /> .,,, r, t.....a•..,.n, M;ux. , rP ;..., nv .:. „,;.,q „t3,.. vroh a^,�' ,+ '� .+t.:;.;a i :2<'/I +� re., + l r ti: <br /> a✓., s + � � r.s � r ✓ .�w r � z / M , �° s r✓ ✓ r � � �� � r ,r 1 <br /> � tdat11+4� ,T � � � �.� <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Service Station 0 Hauler 0 Agriculture 0 Shredder Other j - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> p V A HAULING AND MANIFEST REQUIREMENTS <br /> 10 Notice Of Violation Q Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> f•'�r . ,:��. �- f t. "-m^� f. ! T I •- ��•=t..�:r'2'.� 1.✓C,S`fir' ���,r a',C'� <br /> �;,;:��- ...�•;;;.�„ 1 rt„ �•'_�x' { r. `, c.-r � - - C...7r�'- 4''Vi,:..�`<�' ",•-.�. i (S_- — i f'�.'.. <br /> INSTRUCTIONS ON BACK Correct: Incorrect: i <br /> r P l 3 62081 <br /> ■ ■White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />