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■ =-'=®. Wase Tire Su�y & Inspection Report_n_s ect_ion Report NumberState ,.,. � <br /> O!® <br /> CIWMB <br /> f 81(Nrnia Survey Form - Page 1 V 10760 <br /> ' <br /> ., CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> np� tcrt ''S <br /> t" �t <br /> _ + 4' iuG`�..'✓ k' <br /> r'"ru <br /> TPID- � � Inspection. Type (Fill one) ` <br /> Site Suffix: x -Dr f�T <br /> -� Q Routine 0 Re-inspection 0 Referral 0 Observation ' <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name (.1 Inspected B <br /> p Y Inspector <br /> L- <br /> Physical Address <br /> <; <br /> Street <br /> Inspection Date ) <br /> City. . State ZIP Code Time In Time Out_ _— _ <br /> Busln ess Rep Title O AM 0 AM <br /> 0 P 0 P <br /> Operational Status Tire Type 77Business Role Storage Typ <br /> ! (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that app <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude I p 0 Closed 0 Altere <br /> GPS �L�I Q Hauler 0 Indoor <br /> F_IE C 0 Inactive 0 Truck <br /> Longitude — L____ �� 0 End Use Container <br /> Planned O Q R <br /> Business Type (Fill all that ap)„0 , <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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VV A HAULING AND MANIFEST REQUIREMENTS <br /> - 0 Notice Of Violation 0 Extension <br /> 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 f 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 11 0 Other: § <br /> Comments 1 E <br /> f /fit p , <br /> !l t.{ ,r + .( --- <br /> -- - _ ' <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: <br /> 62081 <br /> ■ White Copy:CIVVNIB Yellow Copy:Operator Pink Copy:LEA <br />