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Waste Tire S & Inspection Re or Inspection Report Number <br /> : : p <br /> ■ y _ State of California Y � � <br /> Survey Form Page 1 9. 1 0. 0 0 7 7 1 <br /> CIWMB 181(New 04104) _ _ <br /> California Integrated Waste Management Board , <br /> Part A Surve BLUE OR BLACK INK PEN <br /> ���ftl�Sl'1'>#IIl$�7@G',,�IGtt1�4t����' "•i"��" ���k"��� �+"r""d�'"�k t`�W�+r��ra�utl.u������w��w,i`kC'p,��14t`���.'�Y���� �� <br /> TPID-Site Suffix: �l Inspection Type (Fill one) <br /> I ,�}�� I + t <br /> - ® Routine QRe-inspection QReferral <br /> Q Observation <br /> Local -� If Referral,choose referral type(Fill one) <br /> .5Identifier: a'1 j o cl GI L,.,�� C q Y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facili y ame - <br /> Ins ected By Inspector <br /> � I� <br /> Physical Address <br /> tA <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business RepTitle Q AM L1 <br /> l Q AM <br /> r jr/ , <br /> "V <br /> [�LLOI <br /> 1J®PM / I / 0 PM <br /> �• . a „„: Operational Status mtC !� Business Role Storae Type <br /> P ar, <br /> (Fill one only) ) tllrJ(k�ttp(+,� (Fill all that apply) (Fill all that apply), <br /> Active "d a C 1"it Generator Q Outdoor I <br /> pS Latitude O Q Closed <br /> G � <br /> � <br /> Q Hauler 0 Indoor <br /> Q <br /> Inactive <br /> �"�:l"ykrwt4�r;F <br /> {'a'f <br /> Longitude - ( Q Planned Q End-Use Q Container <br /> I <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q 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 <br /> - 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 ID <br /> 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) <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 I CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q § y q Q In Compliance No Violations <br /> 14 CCR 18462-Manifest System Re uirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments ( ( ) <br /> - ;a�ttl� k1.._ n�lji <br /> i�'/�n ii,-4' I`l.'-{' �(1!! .# C'(sca r 11 1`r-i�;Y� ''j`: l It�l•.'t (rt�:.4=( (i V1 _-4 f I �t f+"�: ;✓ .J j Y ; � <br /> G'(. 10 S 1! f% I V I l I!i!•fr 4l f C_ ` `I t� �I - l r' <br /> Ids ,l 4?lyQ0in <br /> , cluded Qira+"'r” "" 7r "'x{"" ' <br /> „;�. aria 4 r++ a u f �" , '�'*id'%'r d <br /> qr <br /> . . )W.„( ,r ,,1 <br /> Comments Included. Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X62081 <br /> I 21, <br /> ■ White Copy:CIWMB Yellow Copy:Operator k^Pink Copy LEA u�` yTy I �� ® ■ <br />