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Waste Tire S:ur4k & Inspection Report spection Report Number <br /> ■ ..i,L ...: State of California A ■ <br /> Survey Form - Page 1 1 - 1 1 3 5 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board -._ _.. <br /> Z114 - <br /> Part A- Survey yy BLUE OR BLACK INK PEN <br /> BUSIneSS Profile ,µ �o ✓ yz✓rJjip.r n�Yy !'M ' tbc [etafl3 r rr^rr/yr h w✓' 't Gid ✓ l ✓ <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' _� �� / D Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �.-. If Referral,choose referral type(Fill one) <br /> Identifier: <br /> CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> r. <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street Inspection Date <br /> TiITime Out <br /> City State ZIP Code men n _ <br /> Business Rep Title 0 AM 0 AM <br /> O PM O PM <br /> �._I I — <br /> r.;i Operational Status Business Role <br /> P 1 �iaM,a �f�Y �'w+ ✓r zP <br /> (Fill one only) (Fill all that apply) I✓, (� c� pyy <br /> tau✓, x>��✓�7¢t✓��� � ���" �>�1't�ry >*t�rk( r' k` <br /> 4Active r �u "sr� i`,✓" Generator ✓ll��' L „t�rt ww <br /> � <br /> R ,{ rie✓ tafny yl✓°,� <br /> 0 Closed 1 rr�y✓� �1arr�"«��s r�A a <br /> Latitude " rrr�4G ✓rr 0rgitr� ekyrt rel✓� 1. <br /> C7 PS m . ,rL,ru 0 Hauler <br /> _...._.._ 0 Inactive )" h ` ✓ Mia p,��ry �'r!�"r> y„rlmprA <br /> 0 End-Use <br /> Longitude — 0 Planned �r ,v � �( , �fmrk �tim✓,`'i <br /> BusEgesr Tyle$ <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 /> V A HAULING AND MANIFEST REQUIREMENTS 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 0 m m <br /> 0 0 114 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 1 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I 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 - <br /> -7 <br /> Inspection Farm 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 <br /> White <br /> ■ Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />