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Ins ection Report Number <br /> y Waste Tire Srey & Inspection Repor -- _- p- ------ <br /> California <br /> CIWMB 181(New 04104) <br /> _ State of Ca I jj 0 13 j <br /> Califordd a Integrated Waste Management Board Survey Form - Page 1 i L <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> TPID- � tF J Inspection Type (Fill one) <br /> Site Suffix: Routine Q Re-inspection <br /> ection Q Referral <br /> Observation <br /> Local -1 If Referral,choose referral type(Fill one) <br /> Identifier: A Lo6-C Lok, � U' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r Inspected By Inspector <br /> ssr <br /> Physical Address t. <br /> o <br /> Street f �_ lEu <br /> _ (• p.� Ins ection Date '� -G {� ,7' <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ��] mOPM 0 P <br /> -LOperational Status I+ tfH Business Role t <br /> � (Fill one only) ' � ),l) �d����� (Fill all that apply) <br /> �a., '" t < 'i i i✓�rM"� ��+�"lf �r„;�{{ i N n"�,Mr+ti�,a fir✓Mr <br /> y:a , n " w.�r i r`�"*✓ �`"�' 7 la "R �r r t t�m <br /> ®Active (D Generator <br /> _ r� ',�✓ r/,'��/4f,9as m✓✓�✓,�✓i V^�✓`wr4"C,,�#d� 4k�/ M <br /> Q r f� �✓✓ o� r r1 m r�r,"v <br /> Q Closed <br /> GPS Latitude v,�ry� �t�tr Y '✓e 6 Q Hauler ✓A +�{ x ^1e �� y. <br /> s✓ 7�� ���1 r nr/ <br /> — Q Inactive r tyytp ,�I <br /> Longitude – Q ;" Q End-Use <br /> Lon <br /> 9 Planned r ' <br /> ✓� �H^t �),�r.! y �� ����s �`'ir�i� r'yU; �J. <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® 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 Q Other <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 /> 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / 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) j <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 In Compliance - No Violations <br /> Q O Other: § -- <br /> Comments <br /> �� �Y',.( ���.���4'�(v,i �G'��` .e1a� �_ l►:�_ � �v/�r r i` LI .� / ��1 ='� R ,��`�t _ <br /> i�t' I�, �`fi. L r•' L:y7`f�lJ�-i ! c./ l:'.� [_L: <br /> C. <br /> r <br /> w <br /> �.•���.� N „+ w � .i . aF ar :,.xin ,.r .. �y:,;,, i�filY y .,+u,fH::�:. ,,� ,�+ �„ )s ✓r✓ `F 7y : C d.M1.. ",fi NF <br /> ,r� nt „" �.0; r o-f u' `e. "' ., y w rl ' ,�, w..•q' ,�'q '!"�? r x»"� ✓u'1 w ;4° a r rW'001.,. <br /> . <br /> INSTRUCTIONS ON BACK `Correct: Incorrect' X ,�' �/ N. , , � 62081 <br /> White IV - --- - ■ <br /> ■ Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />