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Waste Tire Suy & Inspection Repor Inspection Report Number ■ <br /> State of California -CIWMB 181(New 04/04) Survey Form - Page 1 o - i <br /> NANO0 59 <br /> California Integrated Waste Management Board _ - - <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: /j } LI -'I , <br /> (P Routine Q Re-inspection Q Referral Q Observation <br /> Local "� 3 If Referral,choose referral type(Fill one) <br /> Identifier: t16^ <br /> JCrt f�[ v'% � I ; � y-, ,.-a Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> p Y Inspector <br /> Physical Address FT,? r I <br /> Street <br /> c� Inspection Date Q l `- J_,.._._'r 11 lE_( <br /> City State ZIP Code Time In _ Tim_e Out <br /> Business Rep Title 11 O AM 1 O AM <br /> r`4 ' - , ✓� c �_y r / � C ._�..._ __o__J � �— ��O PM I � �� I O PM <br /> Operational Status Business Roles � F <br /> Tt <br /> (Fill one only) { (FIII all that appIY) <br /> c�� � � � a✓ �� ,1't <br /> (0,'i Active �� / ®>Generator <br /> O Q ClosedLatitudeGPS <br /> (D Hauler �% Ilot yr <br /> ----- — _ _o Q Inactive 't x <br /> f,' 7 r <br /> LongitudeEnd Use <br /> Q Planned <br /> r+Y <br /> ,,:... sok ElSyT^q }.#:'i ,.'; �1��y� •.. ';,/, H✓ i i ,r , ifi," l 1� a x, H, .,, w pr..-.+ ` u w .;`76*. a �' ,y. ,,� ;, G, r,., <br /> �.0�ti�.a��il..'�"..�"�[^, <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 t Other <br /> ;a4 J <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> O Q PRC§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 <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m �Q' Q <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV orEXT) <br /> I _ <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 <br /> Q Q Other: §L <br /> Comments i f, <br /> / 1(i, tr-Lt,f <br /> j ''✓ V�C�t t 'i 4if {_'l.f '1 Oki,i.('s✓ � �/.Q t1C)� �1�,1t�✓(( t#'1 r i;-i,n(� i[ r �� YI''_.�G4rt � � r' <br /> �f�'rt�'yVi i' "fly) ' ,_IY ri�i"�Cclri t�✓ �!! j�JIL(: 2F�= f, <br /> .HIO '7!V•e_., F <br /> INSTRUCTIONS ON BACK :Correct:* Incorrect. , " L 62081 <br /> l___I <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> I <br />