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Waste Tire Sur* & Inspection Report spection Report Number ■ <br /> Nu <br /> State California <br /> CIWMBB 181(New 04/04) Survey Form - Page 1 1 7 10 1 .3 0 7 2 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> SpeC ,�nrv�e ) >tr^e <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ( ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �C Gt( q(r7 ���y� 14 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name rte' Inspected By Inspector <br /> t l 'l <br /> Physical Address <br /> Street <br /> ( � Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> �j -- 0PM OPM <br /> �— iqOperational Status Business Role t + t , <br /> T <br /> (Fill one only) 1�a)1 ��d ^ (Fill all that apply) rti <br /> [`/J') (/�f "� it"",rv.'a Y'yy�Fa 4"#a� � " r°✓��+� <br /> ® Active (a Generator <br /> QCIOSed <br /> n h ( y ". Ylrpw^x A. <br /> LatitudeTT �^ <br /> GPS Qtr ��yr �M �rN: Hauler <br /> inactive �it �riw <br /> O <br /> r;eat � t lGa�a t rte� ry i �, <br /> Q End Use Iwo <br /> Longitude - � Q Planned a ii�� ,���,^% i <br /> .: ... ... s ,.e" ,.... ..: :.:" ,.. 0n �''� ra'r'Tad..4iwa ir.:� .+Yr..„`� ,r^lfa�„4� �aa`✓�'�' a rw ���a"wps-, yr`�'wFa,","'_ p'`,�r�r-�--ra"�S r+Y; �� p"i”, 7 `a" <br /> r r , I a,,> " .ar N r.f 4 A`,a!'�m>a a a a` 7:! 4 ^,,t it t,a"v r;t4 "g1rf"�r4 C M✓wY../ f $�"uk 7{a^Y,� a eir r t f <br /> Business Type-(Ftq allfh, <br /> ___, : x.. 0 ,_,.m rr a a�tf:';.. t,. .._ . nam �,.,�. .y �..� r. . ✓r,� �L�.YW, . .r�. r. , _lin., -r ..�L...^ . <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q (1) PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements bate f} <br /> Q Q 14 CCR§18459.1 (a)(b) (c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)- <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers j Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations w, <br /> Q Q Other: <br /> Comments <br /> 0. 1A t.a h 0 <br /> til..)p t�C ` t/p (�'Q�t_vt I c G�t�`P JZ ,I�t S Ct liA <br /> c Y P dl —[Y,,- (I m f_h e-41' <br /> r t +r <br /> OfTlm@fit r`���I 2 t'4M"" rva f���� ,ty��Y�:�n� n•h tattq�s<wtW,ty z 1r <br /> INSTRUCTIONS ON BACK Correct: „ '' Inc"'rrect: X "v ,� � � J s2os1 <br /> Yellow --- ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />