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■ Waste Tire S ey & Inspection Repo _Inspection Report Number <br /> or y Survey Form - Page 1 1 .2 - 2 4 <br /> State of California r <br /> CIWMB 181(New 04/04) Y ('� - <br /> California Integrated Waste Management Board `�J' _-. ... 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> S�eID�ICAtT 0"' r a i rlt Vr" o'ra i s a <br /> TPID Inspection Type (Fill one) <br /> Site Suffix: � - (9),Routine Q Re-inspection Q Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: t't,: t 7 s)Ci 1. ( t i r l E i(< ttTl Q CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> P Inspected By Inspector <br /> V. <br /> Physical Address l V 1't i1 t., x L•� r _ <br /> mss_J�'rjr� �r t' r ��('✓Gf��J � <br /> Street <br /> ( Inspection Date 10194J <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> • � QPM ' 0 P <br /> 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 O Outdoor <br /> GPS Latitude = . L- H(( � OQ Closed Q Altered <br /> O Hauler 0 ndoor� Q Inactive J ruck <br /> -T . X1 <br /> O <br /> Longitude — 1� 0 Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill ail thrat apply) <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet O Government O Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture Q Shredder O Other <br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Vart A HAULING AND MANIFEST REQUIREMENTS <br /> Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation Q Extension <br /> Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date Ell FTI / m <br /> Q 0 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 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> �� .I ; i� �, � ��,,.f✓" f�•.i_ ��.t f ! r� ir^'l _"(1 tfv `:� j v 1 y4%11 I^�C' � E r'' �" �.i` r"t!= �� <br /> fi, rt i td d f( t , i V �n <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number-P.J.- <br /> 62081 <br /> umber .62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: _'�.._ � <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />