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Waste Tire Sy & Inspection Reporoflnspection Report Number <br /> State a . <br /> CIWMB181(NewCaliforniSurvey Form - Page 1 i 9 - 1 0 0 5 6 7 <br /> CIWMB 181(New 04/04) ! <br /> California Integrated Waste Management Board -- -- ----- --- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- /� Inspection Type (Fill one) <br /> Site Suffix: , �j Eu 2 Routine 0 Re-inspection 0 Referral 0 Observation <br /> CL - <br /> Local , I , If Referral,choose referral type(Fill one) <br /> Identifier: `1 lJ(i, f, � _ f, t l > 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name _ <br /> Inspected By Inspector <br /> Physical Address <br /> f <br /> I 1 1,i ; Cts r� L•''� i <br /> Street <br /> � � Inspection Date <br /> (�-. <br /> City State ZIP Code Time InTime Out <br /> Business Rep Title O AM � O AM <br /> 1 _ L___.(`— �� : -- OPM � 0 P <br /> Operational Status Tire Type% 2Y/ryMr Business Role Storage Type <br /> (Fill one only) (Fill all tha(rr (Fill all that apply) (Fill all that apply) <br /> p <br /> Qetius 0 Pass" Generator 0 Outdoor <br /> LL�� Closed Alter <br /> GPS 0 0 <br /> Latitude s �<° Hauler Indoor <br /> O '® Inactive 0 Truck <br /> . .-.._... n <br /> i <br /> Longitude — . 1 � 0 Planned U OTR to End-Use 0 Container <br /> bw <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Q 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 0 Agriculture 0 Shredder e Other I _f kii ( I / L'(. k- / <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use-Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> — - 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 <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB IT] <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/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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> 1 ,c <br /> Comments ik `1U, i C��� % r}'( OY1 7 4°Lt G�fi 1 i'''•.f ! - ! y' rr <br /> �1i t t.t f 1 f C {{ Al `, ., Q t r i l L U_ 61 <br /> 1'lrt.I 1 � �:�/ /�I�)��J / \� � ��' 1. oyv 4,4: VIA ( /I(?( I`/ V,I z_t <br /> ,..:h �:. , ,✓, ..,..,. �'S r�, , .... ".'fur l* ., ,.r„ :f ,, -.,rr�,; .,.. , ,a... .t n a� M, .,.,. <br /> -N �/ "._... _ .3 62081 <br /> . r. <br /> INSTRUCTIONS ON BACK �I Correct: Incorrect: , .2 '.3 <br /> N <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />