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- Inspection Report Number
<br /> Waste Tire S0rey & Inspection Repo
<br /> State of California � -- ---
<br /> CIWMB 181( e ) Survey Form - Page 1 f 5 - 1 0 1 3 0 8 7
<br /> California Integrated WasttManagement
<br /> Waste Management Board I
<br /> Part
<br /> MgE -A Surve _ BLUE OR BLACK INK PEN
<br /> G 1 Dt'�+ 't''.7"ygn"�t/n >
<br /> Insp rH �y R
<br /> T t a tlt� n
<br /> TPID- � EEInspection"Type (Fill one)
<br /> Site Suffix: E i1 { I (0 Routine 0 Re-inspection Q Referral Q Observation
<br /> Local '7 If Referral,choose referral type(Fill one)
<br /> Identifier: uCA(/I _t{� r% i 4, {
<br /> Q CHP Q CIWMB O Complaint O Educational Visit Q Other
<br /> Business or Facility Inspected B Y Inspector
<br /> ADIE E Ct. ) rl(t�(�JI "lR ll. jL° p
<br /> o � ��K t--� � r
<br /> Physical Address l/ J — ' �? 17
<br /> 1 �Inspection DateEu / / `
<br /> Lai
<br /> r
<br /> City State ZIP Code Time In Time Out
<br /> Lj 0 AM
<br /> Business Rep Title Q AM
<br /> } y j O --- ___- 0 PM
<br /> I ._� c)f..-'t L,\ Ct L PM
<br /> Operational Status Business Role b" °a
<br /> { (Fill one only) + ` r" (Fill all that apply) l (1 "' il�.
<br /> (0 Active ;fpr Generator � �,) a'
<br /> Latitude
<br /> J' O
<br /> LatitudQ Closed
<br /> GPS
<br /> ,i irk rtfNyr+tf/lrMnetr� 1"nd
<br /> �
<br /> J yy
<br /> 0 Hauler
<br /> Inactive
<br /> � a rr P °r tr h r lay
<br /> U9 A c
<br /> Longituden ra
<br /> t
<br /> � - "
<br /> Q Planned � End Use
<br /> 4
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<br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet Q Govbtnm nt O.e,R". ea-.r^rtrer/a„f'+^bdn�,a e,„a.��.,.r,,t,-.,..�,,:�,�,�r,r��+^'�"�..�.,�.��r,,r.„�,,..na,...n.7��e,.�i,�.I,:.,��,..r,.r^.+k.,,,,Y':,C-.,.a...,:.an.����n�,r r�✓t�e-t�,^,�m,.,,-„�..:.l„.:a,.,r,r r a°a.Yr.,i'�n.�i�t!�.rwi.l�.aa„.rx..,�,...��.,�..,irru Y�r"�F�Prrnv` a��r*ns�,r.rmC,,.�ur...,n,�t..�A
<br /> "l^^
<br /> �nCr”r
<br /> .;..:.
<br /> Q Dismantler Q Tire Derived Fuel
<br /> Q Used Tire Dealer Q Auto Body O Car Dealer (� �i Collection O Crumb Rubber
<br /> i
<br /> Q Service Station O Hauler Q Agri ultul'e "JI'`C�Shredder O Other t 'w�!
<br /> Part B - Inspection of Waste Tir1 Dealer/Generator, Hauler and End-Use Facility. j E1. NFORCEMENT STATUS
<br /> V A HAULING AN!;!#0109ST REQUIREMENTS NO
<br /> Q Notice Of Violation Q Extension
<br /> Q 0 PRC§42951 -W ste Tire Hauler Registration and Transport of Tires
<br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. k Compliance Deadline
<br /> O O PRC§42956-Registration/Decal in Vehicle
<br /> O O 14 CCR§18459 -Responsible Entties Complying with Manifesting'�equirements Date /
<br /> m
<br /> Q §18459.1 (a)(b)(c);:fjre Program ID Number from CIWMB
<br /> 14 CCR m
<br /> Q 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV orEXT)
<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 /> O O 14 CCR§18462-Manifest System Requiroments for Tire Dealers or Waste Tire Generators Inom ce -
<br /> G plfan No Violations
<br /> 0 !. 0 Other: §
<br /> Comments ( r { t f I
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<br /> rt b4 u"f fir' M w
<br /> X � � 62081
<br /> INSTRUCTIONS ON BACK Correct: Incorrect: ]
<br /> White Copy:CIWMB Yellow Copy:Operator
<br /> ■ - ® ■.
<br /> Pink Copy:LEA
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