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Waste Tire Su & ns ection Re Ort Inspan Report Number <br /> Y p p - ---- - -- - <br /> 6gzSi State of California .' <br /> CIWMB 181(New 04/04) j{ 1 - 1006 ,1180 <br /> {i f/�i �/yj <br /> California Integrated Waste Management Board Survey Form - Page 1 } { 0 1,j 1 8 0 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> i <br /> I hl Ii r. X 1"t Ir,���U/lYr r� 1✓""'r �m,G- i �"q�m� ^:ry�./ ?" �, � rr., <br /> TPID- Inspection Type (Fill one) <br />} Site Suffix: ( $ f7 r l V Routine Q Re-inspection Q Referral Q Observation <br /> - — --- <br /> Local r F If Referral,choose referral type(Fill one) <br /> Identifier: i t OC,(" r.{ D ( �G(41 O CHP Q CIWMB O Complaint O Educational Visit Q Other <br /> or Facility Name <br /> Business <br /> E, Inspected By Inspector <br /> usme iJ Lrlr <br /> Physical Address <br /> i <br /> Street <br /> Inspection Date <br /> L__...'_. �T• f1 f ! ( - { -Y I <br /> City State ZIP Code Time In Time Out <br /> _._ <br /> Business Rep Title L �0AM Q AM <br /> _ -. <br /> Operational Status Businessr o I i <br /> (Fill one only) (Fill all that apply) <br /> Active r ® Generator <br /> _ 0 , � ✓i ur � r n <br /> «✓ Y w 4 « � <br /> Closed <br /> G PS Latitude 0 Hauler <br /> �_J <br /> 'r <br /> Inactive <br /> ✓- O � yu P" a xr hy(I"t�"r`rn <br /> Longitude — 0 Planned Q End-Use r <br /> WR <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer 0 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 I: <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date' r <br /> M <br /> 0 0 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 forNOVorEXT) <br /> Q Q 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 Q Referred f CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generatorsr�" `"``�'ir' °( �✓ <br /> o violations <br /> r� t <br /> O O Other: § , <br /> Comments j k <br /> { TbS ? r�11 ( '"• ( l <br /> t11���: VIL�v1r✓��-� i�.1� �If I l;{:�L� � (_ 1'J'�'`�`t�( �s"!� T �(���1' i)r"I �.J_ ��`tUiatt '�?r �: �'!' <br /> s <br /> a <br /> � ra <br /> r h « � <br /> a u � <br /> « <br /> r l r y <br /> r <br /> it un.'u�'�'a"d'*,�' �"^ � �" ;� �,✓ �i r'" <br /> " fr9P,, q ` ,rr?. ✓/ Y: LIS 1eS5 �15 1:'rMK -TRIm4 _a✓,,:r, eCt 11 ;Y t i' "I.1?n� tr)l <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: incorrect: A ,r , _j__T 2 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />