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•;_��:��,-d Waste Tire Sey & Inspection ReporoInspection
<br /> Reportort Number
<br /> State
<br /> State of California
<br /> CIW10 4
<br /> #
<br /> 1MB181(New04104) Survey Form - Page 1 j
<br /> California Integrated Waste Management Board
<br /> Part A Survey BLUE OR BLACK INK PEN
<br /> z S:,s* =1�r; .;u"." ,f7't,!^µ; ,� rE �"t
<br /> Inspection Type (Fill one)
<br /> 0 Routine 0 Re-inspection Q Referral 0 Observation
<br /> If Referral,choose referral type(Fill one)
<br /> Identifier: j t-`.. i,}a V'. t r+ .r( Gl.�". (0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name Inspected By Inspector
<br /> Physi Cal Address L 2-I11 �j
<br /> Street _
<br /> —t - Inspection Date
<br /> city State State Z/p Cocle Time In _ Time Out
<br /> Business Rep Title fAM
<br /> LIE
<br /> . ( J O PM 0 PM
<br /> - Business Role
<br /> Operational Status �,� � �,� n, , �
<br /> - (Fill one only) ti r (Fill all that apply) 01`0I( y
<br /> ® Active ® Generator *
<br /> D 0 Closed
<br /> GPS Latitude Einactive
<br /> ! rr s ,+, ;
<br /> r aw( n �k + n 0 Hauler �„ r „t}Ir,d
<br /> Longitude 0 Planned +I (a End Use
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<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 (M 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 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-Registration/Decal in Vehicle
<br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m
<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 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 In Compliance - No Violations
<br /> 0 Other: § ---
<br /> y/
<br /> Comments j .f jYI �1(.✓E�( 1Y+.` Ci .v1 �Lt jCj
<br /> L'lftx s IdP<< t
<br /> Ifr:r {'10' 1i'01.1 'V!'/,t� ''C.f
<br /> :iJ l ,I17 ltd /
<br /> " 62081
<br /> INSTRUCTIONS ON BACK `C recta Incorrect: X , " , JAM L
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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