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Waste Tire y & Inspection Repo inspection Report Number <br /> - <br /> �, � CIWM 181(New Survey Form - Page 1 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board -- - - --- .--- <br /> Part A Survey BLUE OR BLACK INK PEN <br /> ......... ,, <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: - LE Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date / EE <br /> CityState ZIP Code Time In Time Out _ <br /> Business Rep Title M <br /> Q AM 0 AM <br /> 0 PM __.F—E] <br /> ' ._._ O PM <br /> I - r �a r <br /> Operational Status r �] , `r a Yd Business Role <br /> (Fill one only) � I" t11 )'R (Fill all that apply) <br /> Active d{{ P�IS�'se1���F:rr+ 0 Generator ta'„ �4f��ftPt �r„,y i��MENKE . <br /> PSLatitG0 Hauler �"y '���{rr1 Mmaltrrrr�u N rrr�Ua,ude 0 Closed <br /> 0 Inactive <br /> � <br /> ` <br /> a� � aaaa r <br /> — �0 )a a ra 4a"a M fru lr rta a[ Y <br /> Longitude - Planned � � �,rrtn 0 End Use <br /> q a� } a "r'� ry b w*d 7w;wP a amr �. <br /> 9i, � +ar <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 0 Other 1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> PRC 42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation Extension <br /> V A ��HAULING AND MANIFEST REQUIREMENTS <br /> § 9 P - <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle \y <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 0 / m / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <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 O <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years I <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 <br /> �0 I <br /> 0 n Compliance No Violatioris <br /> 0 Other: § <br /> Comments <br /> fy r`9� is �� �R � � "rt s� ti •q,;„.. a r•� t�F"'.lM, �"� 9 a;��r�rvf7 vr��y ��F{a nla/itd <br /> P 5 �� ,.;P�, r�'H wa { :..;1 1 a �f �+ rr,a�"'a' ��r+ �mM1� r na" '�ti• f <br /> "Pone" <br /> n s(hep 5 !"1 i1 1�1t <br /> INSTRUCTIONS ON BACK Correct:IS Incorrect: �' �'"1 '�� �1� � 62081 <br /> --- _ <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />