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Waste Tire Su*y & Inspection Report ' Inspection Report Number <br /> State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 - i 3 10 10 7 2 7 <br /> California Integrated Waste Management Board - - - <br /> Part A Survey BLUE OR BLACK INK PEN <br /> tlt ¢ins��f ,"Details <br /> Inspection Type (Fill one) <br /> Site Suffix <br /> Q Observation <br /> - Routine Re-inspection Referral <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 /> r1 ),t <br /> "'], <br /> Physical -Add <br /> ress <br /> TE0 <br /> Streetf. <br /> t J Inspection DateE,, <br /> / 1E0 <br /> / C'f p 1 <br /> tJ J <br /> Citi State ZIP Code Time In Time Out <br /> Business Rep t J Title O AM O AM <br /> 0PM � ' 0 P <br /> Operational Status, Business Role tflr <br /> rQCTt1 dMl(Fill one only) Ilht )i !+ (Fill all that apply) htry <br /> ® Active0 Generator ! � lyf„,'� <br /> 0 Closed r r It �r v >rl i1 <br /> GPS Latitude m . �rr i ) rL i0 Hauler1 � <br /> 0Inactive <br /> why ” Asa ly i;ip r f v <br /> O <br /> Longitude — J r" �" �k '`u7F + i 0 End-Use <br /> 9 0 Planned <br /> it it,- r�"H,,,.Y,^iq ';' u,` "a ✓�,`s,� t y 14i ^"` ',` " fi �' `*' 1rt/ ar„'d Awa ,Pny, �H' Vv��e% 3°a,�„"E; yYlf >" "y-,, <br /> b <br /> ✓r...., t �r.Y I, r,,.,. F a� I)7Fa,,.,„:. rf)” ,4 .,. r +,. r �' �. lt(tt,,,. <br /> 'J00; ,;c?, <br /> _ w, .� <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 <br /> i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A _I HAULING AND MANIFEST REQUIREMENTS 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 <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 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance- No Violations <br /> 0 0 I Other: § - <br /> Comments <br /> L'( ! <br /> ""!"N If. I f�t'' <br /> T- <br /> - <br /> Inspection Form Included: 0'. <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> .. ' i 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />