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ns ection Report Number <br /> Waste Tire Sy & Inspection Repo p p�� State of CaliforniaC®®d. -. CIWMB 181(New 04/04) Survey Form - Pa e 17�L <br /> 4 006635 <br /> California Integrated Waste Management Board ! �+ "— - - -- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> __ y _ -- <br /> TPID 1 _.� Inspection Type (Fill one) <br /> Site Suffix. IL \ I !'- �- I W ® Routine Q Re-inspection Q Referral Q Observation <br /> Local - If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address } 1 <br /> �Street :.� f <br /> Inspection Date EE <br /> city State Z/P Code Time In Time Out <br /> 0 PM , [T 0 PM <br /> Business Rep Titlej L AM <br /> AM <br /> Operational Status" ' rrr " Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply)!. <br /> Q Active � � t ti Q Generator Q Outdoor <br /> D`� Q Closed <br /> GPS Latitude WMM a t t mtFr Q Hauler Q Indoor <br /> Q inactive � � 9(i✓`� - <br /> o 0 7 tr Q End-Use <br /> _r Longitude - Q Planned t Q Container <br /> ws , , � '.s'�x $,,:,N .:n�, r .:.. ,r .c; ,.;., y .;:' 9 y��<fi r'P✓,rv,S ., ,...., 111 r ,: —�, �7 a•.r F'p�"!"'"�"rd'µ✓�,�"F", �.!k'r��'+'�"+`� , <br /> u.�` �, .8'$ '�� 'its? )I.fex .::.: ;'.. � �Wt ?n arXv i "7,Y�✓"q,.ri" ".,'r ra4 rC:,.Y'�9 dtw, ,am�Y? i�riN;r"x� r,�,.r�rs.'?�t 1.�,--5"...��+..��.�.�"�".;,k�^�. 1?s� t:n;G"." .?'r"twMk,.,x�f�, kN,.r, <,. �a.�n <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 1 HAULING AND MANIFEST REQUIREMENTS <br /> ------ ----. Q Notice Of Violation Q Extension <br /> --- - --— --- .----- <br /> Q Q tPRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <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 /> - <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/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 Q In Compliance - No Violations <br /> Q Q Other: § —— -- <br /> Comments <br /> t <br /> Inspection Form Included: Q <br /> Comments Included: O -- — _--- - - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X ✓ i L x i A lb"°1 I-' I_ F <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />