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wx <br /> Waste Tire SuOIII & Inspection Report spection Report Number <br /> State of California , A . -- ■ <br /> Survey ForrnP- Page 1 Q <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board 1. <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> , ... yi� 3�`t� y,',7+Y`" i54 "lx �hb�>l'a (M�" Turw�rY i aj�i <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix- Ll I (0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� ._ If Referral,choose referral type(Fill one) <br /> Identifier: ��i " <br /> •. , f f rr, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical 'Addreps <br /> T <br /> Street <br /> !_ Inspection Date <br /> City State ZIP Code Time In _ Time Out <br /> Business Rep Title 0 AM OAM <br /> 0 PM 0 PM <br /> rau Operational Status / �r��rx�� Business Role <br /> (Fill one only) rig� (Fill all that apply) I; Fillatl" <br /> ® Active irai @ Generator <br /> — J�'��J r a��� �' rd��� t��t»�p+��yyr«,rrMr'tgw n�`rr�r✓na�" <br /> GPS Latitude 00 Closed <br /> 0 Hauler <br /> � Inactive � <br /> Longitude O <br /> �, ptkt�i�a�fa 0 End-Use �Y ��It <br /> 4 0 Planned <br /> — Fal ' a ;,r 1 �J c E s,,:N ✓'1P''�, r" �'r Ml,,. ; a P�"�' a�v^ 6 %tl�?r � :rt �4� u,.a �'"r,4 �' ,��'� 7�4 r r <br /> ."* ,.. a , , ✓ a r �., a rw,.a;, �'a f� �h M;e �.v <br /> .,sW.lJ,. <br /> .,,„,,4 "rw;.3r o ✓h< r r�,a v u.,.na,,,2a ,^ C as <br /> Q 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 0 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-Regis-tration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements pate <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 Haulers0 Referred/CIWMB Enforcement <br /> _ <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 <br /> 0 0 Other: § 1tt rompliance,,,r. No Violations <br /> _. <br /> Comments <br /> ! . <br /> Gl <br /> 47 <br /> Inspection Form n � - <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ . <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 62081 <br /> k '; yY�, I_ V L <br /> ■ White Copy:CIWMB Yellow Copy:Operator NPink Copy:LEA © ■ <br />