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Waste Tire SU nspection Report Number <br /> r�y & Inspection Report � _ - _ _- <br /> ■ '. .: : State of California .a <br /> t CIWMB 181(New 04/04) Survey Form - Page 1 1 8 1 0 0 $ 0 <br /> California Integrated Waste Management Board <br /> Part A- Survey eypp BLUE OR BLACK INK PEN <br /> Business Profile ' h E2 q7i r ti4t rro i !F •/abt / r P/ tTa <br /> TPID- + Inspection Type (Fill one) <br />} Site Suffix: '# I co I� I - f 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ( r If Referral,choose referral type(Fill one) <br /> Identifier: f'! '� J tit' ✓-�t GAG t ,' Q CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> �a <br /> Physical AddressL'"i t ) - <br /> Street r� <br /> Inspection Date1,4 <br /> City i State Z!P Gode J. Time In Time Out <br /> Business Re0 AM 0 AMp Title 0 PM ' � 0 PM <br /> r ri <br /> f- iri t :'. 1�4 _`•fit{ter{ I Ml,t� �(� t��r �'� <br /> Operational Status Business Role rr <br /> � (Fill one only) (Fill(Fill all that apply) <br /> Tire Count W <br /> hotelPT " " "f <br /> 0 ,y r� 0 Generator <br /> ._: Active <br /> O ® Closed l� � �)ri "� <br /> Latitude 1Cs a "°g,ararfi r Yt' a 4°ta rt" <br /> GPS 0 Hauler <br /> 0Inactive „kN,��^"rr�„, <br /> O 0 PlanneddnJ,,y, rA <br /> "��dl�` w`rr/ "`5 ✓� `m” fir+ <br /> Longitude - 0 End-Use r u <br /> i <br /> 0 New Tire Dealer 0 Auto Repair 0 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A ;HAULING AND MANIFEST REQUIREMENTS <br /> --- <br /> 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / FT] <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 0 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 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments r' IlK <br /> c4 !7 fil 0 <br /> I tic"I a IlOki <br /> Inspection Form Included: 0' <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X � 62081 <br /> _ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />