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*11 <br /> Waste Tire Suuuuuuuuuy & Inspection Repor*_Inspection Report Number <br /> rrrnia State <br /> ated California <br /> Survey Form - Page 1 D 8 . 1 o I o 6 5 7 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A Surve BLUE OR BLACK INK PEN <br /> ' ✓!°r – <br /> ,IC�il�I4� qrsYc�a�,,q J1:+.1�^'•••. ,' ,—n..:.-,,�, ,xa r-gi(� <br /> n 1rrtw.— ,d . <br /> TPID- Inspection Type (Fill one)r1T - <br /> Site Suffix: �r"ue.`..,✓,�>Lw�r;"��+Cwn''4tdd'i�'ra'�'a.r,r Mz,ryuna.w.��x,i'dar",�u'.a�b,.."�.Pr.�rr,.rkrru-�d, <br /> 0 Routine 0 Re inspection 0 Referral 0 Observation <br /> Local s If Referral,choose referral type(Fill one) <br /> Identifier. ("R."; 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name — / i Inspected B <br /> Inspector <br /> c or <br /> P"hysical Address J - 1=1 <br /> l _ � f •� :, C_j lir;;;{ •, J <br /> Street <br /> l _ Inspection Date <br /> City State ZIP Code Time In` Time Out <br /> Business Rep Title f 0 AM l 0 AM <br /> F: <br /> �0PM � • .I 0PM <br /> r, Operational Status Business Role <br /> } t r <br /> 1 (Fill one only) {I ill SII tIppl) (Fill all that apply) <br /> ¢ was rr <br /> Q Active ' �F se l er (a Generator <br /> �^�v,.r <br /> Latitude 0 Closed "l l" l �rar C rr <br /> GPS � "rr��rrlrr 9x���rrirai� is 0 Hauler <br /> 0 Inactive " Tia tarr �r� r n + <br /> � i r!r rqR afa rr?PC�� r 3�(+ �rw fi„r�par� r.pM� w�"a"a✓ Y"{ <br /> ✓" <br /> Longituder�,r r. 1�.ar a a r�i r �r) Ct a � ,a✓ ,r✓r� "# <br /> itirt� Q End-Use <br /> 0 Planned <br /> rltarr a u <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader (a 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 0 Notice Of Violation Q 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 m / m / m <br /> 00 14 CCR 18459.1 Oa Ob Oc 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 Q 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 Generatorsl <br /> 0 0 Other: <br /> Comments t <br /> f Ur-,ALT,hR(xjWf?l eL <br /> VCL1-t �Y4 /ry/ �fl <br /> _ I <br /> _ 1!!r` -� G i(r�C' ��;��i Jl s;�<� ��.. ��;�/,� - (✓� `:h�� ` r _� v i/i J��¢ �(��f ; <br /> >t <br /> a ,r� C" 5 "a � < �t 1r,~ ,s(W r°d4W>ti•,r,.arv:>wbr'�vt n7Mw� �G��r'Y Aq°rWr» �M� 11111 <br /> l��"��d�_�a <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: f l+ 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />