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Waste Tire SAey & Inspection Reporo Inspection Report Number t <br /> State of California <br /> CIWMB181(New04/04) Survey Form - Page 1 5 - i <br /> California Integrated Waste Management Board - <br /> Part A Surve _ BLUE OR BLACK INK PEN <br /> ttspection <br /> TPID- `` � r.-_ 1 � � � Inspection <br /> �; Type (Fill one) <br /> Site Suffix: 1 —1 � '_` � ! � f Routine Q Re-inspection Q Referral Q Observation <br /> Local f i If Referral,choose referral type(Fill one) <br /> Identifier: t r;y C t�i,ri P'in Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (- <br /> Inspected By Inspector <br /> j—v 4,, — {� `✓ i I,.' r o'1 f i <br /> i_ <br /> Physical Address l <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> t [� �0PM m � 0PM <br /> Operational Status t , Business Role <br /> (Fill one only) (Fill all that apply) <br /> (f Active fst ,r Generator <br /> R <br /> GPS Q Closed � c3 t i. <br /> Latitude <br /> Q Hauler r <br /> _ <br /> � Q Inactive <br /> Longitude — Q Planned Q End-Use <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Gove'rnment 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 L <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ----- <br /> V A HAULING AND MANIFEST REQUIREMENTS LQ 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 / / <br /> 0 014 CCR§18459.1 a b c -Tire Program ID Number from CIWMB Q FFI m <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days j (Required for NOV or EXT) <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/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 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments r <br /> il ,l' <br /> �14 <br /> 6-i' 1. t; t 1.._ 1; >rr ytlG� t . <br /> I - <br /> -:f ff <br /> f •i Vl�_E fll�., f;� `:"Ifi/" fjt? = r 1,€" "s ::%ii' �i t t•..�f-' � <br /> h i• <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: i�' � f' rh� ,� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />