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Waste Tire Stoky & Inspection Repo', Inspection Report Number <br /> �) �Jj 'f�j /L�j <br /> State <br /> WMB1alifornia Survey Form - Page 1 i V f V 1t V <br /> � CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board _ _.,. <br /> Part A- Survey BLUE OR�"�BLACK INK PEN <br /> Business Profile; Inspection Details <br />+ TPID- P-• / Inspection Type (Fill one) <br /> Site Suffix: i( ��-� I ' I �I � '( l (,� f 10 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: 6+6 <br /> G ( f P f (,�i t' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Nameh <br /> U Inspected By Inspector <br /> r!, <br /> Physical Address <br /> y _ F( <br /> �•�.r �r�<t <br /> Ph � <br /> Street ,- � <br /> Inspection Date <br /> City State ZIP Code) Time In Time Out <br /> ­ <br /> 1 I- <br /> Business Rep Title O AM 0 AM <br /> d . ( L O PM 0 PM <br /> a" <br /> Operational Status Tire Type Business Role Stora�ges'�+�n <br /> pl <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill alt,AL <br /> j�t,app)y�` <br /> Active Passenger Generator <br /> O <br /> ® g 0r <br /> Latitude O 0 Closed 0 Altered 1 ((r <br /> CIPS Tv� 0 Hauler 0 Inc)_ a��t <br /> O ne <br /> 0 Inactive 0 Truck 1 " <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> II . «, x. <br /> Business'type (Fill all that apply) <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 /> A HAULING AND MANIFEST REQUIREMENTS <br /> V <br /> ----- -- - - --- 0 Notice Of Violation 0 Extension, <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <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 I 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 1 0 Other: § <br /> Comments i yr - <br /> fu",1 !''' <br /> , <br /> f lit t C�; ',.f'__S_ I(e o r'�; 1 (�';`' I h C TL �r!ill 1 <br /> Inspection Form Includedc <br /> Comments Included. "0� <br /> M : Phone Numberv" , <br /> a <br /> INSTRUCTIONS ON BACK Correct:* Incorrect X . X �,,M P � E Y 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />