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ection Report Number <br /> _ Waste Tire Su & Inspection Report �p p � <br /> State of California <br /> CIWMB 181(New 04104) <br /> Survey Form - Page 1 1 3 - 1 0 1 0 5 2 0 <br /> California Integrated Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> �s+�����a„ 1 �Ysp�t�tl�r). s���� ..�.�tir"�,"„�✓i°" k . .wra>>i'ti:�_�_�.,_..,�,rn�.�.��r`��i.1�".�.,����_,+ �irtt•.r. <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: G - 1 1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /�`( If Referral,choose referral type(Fill one) <br /> Identifier: i I �r;f Cd.t )k 0-1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> LA <br />!! Physical Address ( - ( C l ! j <br /> Street L <br /> //�-,. 1 j/ .-- Inspection Date <br /> /� // y t , <br /> —� <br /> City State Z/F'Code I Time In Time Out <br />'I __..___._ <br /> Business Rep Title O AM O AM <br /> � • �OPM � � _ 0 P <br /> �/a v r �A I {s.t _ �.i i.r r r. [✓ 9 - <br /> I my" - Operational Status t �(/ Po�a ,f Business Role Storage Type <br /> (Fill one only) (Flfl, l1, 1f) (Fill all that apply) (Fill all that apply) <br /> ® Active �i� '� Y"" @ Generator 0 Outdoor <br /> Latitude D 0 Closed � fG( P'"a'q <br /> GPS m • � ar�� yi��1x�;�1/�rv+�`tr'r 0 Hauler 0 Indoor <br /> O 0 Inactive <br /> - <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <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 . Other i V 1r1 -rJ!al" <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 0 , PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 17 / FP / T <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 0 In Compliance - No Violations <br /> 0 0 Other: §`! , <br /> Comments <br /> (' `, �$ a� VVwtf <br /> V ; <br /> J <br /> r <br /> -- w,r ' �" r � ,� �7J5 orfs � 5 r t «�» ,�', �y t P�� ,y � �t ,�1p�, �` d� .� 9• ,,. <br /> Inspection Form Included <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature <br /> _ <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: r ;yI, ,M�,;,' 1. (•: 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />