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Waste Tire S� <br /> y & Inspection Repor� In <br /> _s ect_ion Report N_um_be_ r <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form 0 1sD <br /> 10 Page 1 <br /> California Integrated Waste Management Board "— <br /> - _ <br /> BLUE OR BLACK INK PEN <br /> Part A Survey <br /> Business Profile`. Inspection Details <br /> TPID- �. Inspection Type (Fill one) <br /> Site Suffix: ( I L (� / ® Routine Q Re-inspection Q Referral Q Observation <br /> Local `" /j r If Referral,choose referral type(Fill one) <br /> Identifier: {{�( J ped c (,.f.l,y i j(�`_. L1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r 11 Inspected - <br /> , . Inspected By Inspector <br /> Physical Address �f `� ! L.'" / L�.l pi <br /> (Street Inspection Date ; 'f � m� t`j <br /> City State ZIP Code Time In Time Out <br /> Business Re Title � ; <br /> f' p L� '' QPM [0 ]? I I�—1 ® PM <br /> �) r7r rZ t / ( lath rf !< RI 1 b2 l`r a <br /> rtCR <br /> r ,..�: <. ;+Operational Status ; f 9 Business Role , e <br /> (Fill one only) ��c r (Fill all that apPIY) lkd�l° f� � <br /> Tire Count(Whole/PTE) <br /> Active � r ® Genera s <br /> 0 Q Closed "� �� +� <br /> rt <br /> Latitude f1� Q Hauler q <br /> GPS t��L-, �'' <br /> QInactive G,^"�1 �� �h,,,; r ,rJ< y ;'a"��,✓u"Mf'�', 7✓ <br /> OA <br /> al � r+sr Q End Use �r ��� t <br /> Longitude <br /> 6/ Kik'" rti ,�ft4d�l ori art /tis a� �� MN n* � <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 (a Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 1 HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q 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 /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / ITI / M <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O <br /> 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 1 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 Q in Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments r .I <br /> - i <br /> Inspection Form Included: Q <br /> Comments Included° Q - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number.. <br /> _ _ 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �0 X,A �" , r' 1.-�: _y - - <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />