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■ xA Waste Tire Sl, y & Inspection Repor Inspection Report Number <br /> W1_, <br /> State of California <br /> J f' <br /> CIWMB 181(New 04104) Survey Form - Page 1 4 - 1 0 � Q 5 05 <br /> California Integrated Waste Management Board - - <br /> Part A Surye BLUE OR BLACK INK PEN <br /> „� ° ) w r , r r k �°° nr h/� rr ul° <br /> TPID- Inspection <br /> on�yT�y�ptv�e1 (Fill <br /> l a one) <br /> nr"e) <br /> Site Suffix 1 QRoutine O Re-inspection <br /> °4ecM,ati.ot n� Ow` Rt�e..fe,drr�a�l O.t. Observation <br /> Local <br /> n_ <br /> Local Z (( ) If Referral,choose referral type(Fill one) <br /> Identifier. �� (� "` l ;'G'(�.I O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> ��cic� 1r�n � P ..f� 1Co . -_ - _ - - <br /> Physical Address 1 'l r i-.t- + F-:' <br /> �f V LAJ }r4t.f" i �t.11'i 1f(,c.1 — <br /> Street ! <br /> Inspection Date <br /> di <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> I .� 4�C .��V�'`•-�. - _...—� ''r�i` '.-,-� f�{•'¢ r _ -- a �u}'�'�r'�H say:, � , <br /> Operational Status , fta '* Business Role <br /> (Fill one only) �" � �i (Fill all that apply) Jirf� alY) <br /> I Q Active l"a, p"t- (j) Generator � CutCbt <br /> }"M"�' �7�'"� 7s�r�'�'+�i�t"'�n'} r`1�i ^��r*ar :f �,„ '✓r' <br /> O �t r° <br /> Closed °" ���`E#fl y� °a°}i <br /> Latitudev <br /> GPS EDV O Hauler wylrtitdr ,' <br /> ® Inactive ) i !4}Ck� 7s ° j°° " nsi nyr <br /> D <br /> Longitude - – O Planned ' � � O End-User <br /> ne r yeas)° w <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder Q Other p(j c I j may,f i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VV A HAULMG AND MANIFEST REQUIREMENTS <br /> OO Notice Of Violation 'O Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O �PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O ! PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M <br /> /'m / m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities -- — <br /> i <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> Other: § <br /> O O ------. <br /> Comments <br /> (.-_ ! t.l.1 $ r t' _ _h(...'i_L_ I,r_ tJ t/�,� Y,)/ r(/• /y _ , <br /> y' j .t}J`} Ff�VLtir�t-. �_' 1ii. ili�� � V_ VlL1�}��t! � _y �(rt✓}C� (j++'( ��' <br /> 5 t Iif�. L . 1 ,;:? C,4" 1 sr <br /> ctE. � o 'TL "1;7 , �; - t, .� _. �f "� . <br /> J I , ,, ! r <br /> Inspection Form Included: Q, <br /> Comments Included: 0 _ <br /> Business Rep's Signature Phony Number Inspector's Signature Phone Number <br /> _ _ _. 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X iY_ X j A 1.0.j P�� � 1 �s <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />