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Waste Tire Sufty & Inspection Repor Inspection Report Number <br /> - <br /> ��a�� - - - <br /> StateBCalifornia Survey Form - Page 1 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board -- -- -- <br /> Part A Survey y BLUE OR BLACK INK PEN <br /> In <br /> •,,; r ,"+ s"irµy x* y"�r3c`,"" �" "Ac<�t�fM, �M 1. h+q„r'," ,tG',d„r)xr` :,,t1"„t"'�� t"� +�fir"°w�/`/,", ^ sI <br /> petQ�•,�" <br /> __-_-�...___ Inspection T e (Fill on 0 0 <br /> TPID- ff _ _ ) Type ( ) <br /> Site Suffix: (�! ( l j ! 1 Routine Re-inspection ReferralJObservation <br /> Local ;' t i If Referral,choose referral type(Fill one) <br /> Identifier: - �,� (� �'(,� r. �o 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name / - <br /> 'VI Inspected By Inspector <br /> jf <br /> Physical Address <br /> Street P <br /> �� Inspection Date <br /> City %7 G t, ��_�__ l S to Z!P Code Time In Time Out <br /> 0 AM 0 AM <br /> Business Rep Title LD : O PM : E O PM <br /> V. ro _ <br /> YV <br /> ---�-�I—� Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)', (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger Q Generator 0 Outdoor <br /> - -�t7 0 Closed 0 Altered <br /> Latitude , Q Hauler 0 Indoor <br /> GPS <br /> C Inactive Truck <br /> Longitude o ——�—�! 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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - <br /> V A HAULING AND MANIFEST REQUIREMENTS— <br /> 0 Notice Of Violation 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 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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/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 ..�.. ! �� ( -CX 4 �' � fi��� t.tt t' `r �_)(t l'• ) Rill' <br /> t`iyoo-J , <br /> l% <br /> % <br /> 1G( � <br /> r <br /> _i <br /> Inspection Form Included: 0 <br /> Comments Included: 0 _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X � t:; r; �1.1 is @ L ._ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® M <br />