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Waste Tire Su&y & Inspection Reporolnspection Repork Number ■ <br /> _R <br /> State of California <br /> CIWMB 181(New 04104) JM1 �1 r1 <br /> - Survey Form Page 1 . 1 0 1 0 1 o __ <br /> California Integrated Waste Management Board --- - <br /> Part A- Surve y BLUE OR BLACK INK PEN <br /> SpeCt�O�1 y�.lE'�t,�,t,�5,�„h ✓��-W e.�v'_-..,.... �' ��,�t'w�.�.�....��L�,7 ,�i�^,__1�;.�z_� .r+ <br /> TPID- f:� I �.( f l Inspection Type (Fill one) <br /> Site Suffix: ` 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local -; �`l t 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 /> Physical' Address M1 _ <br /> 'S <br /> Street <br /> (( _ Inspection Date ! f <br /> I ! f—..-_.--i--` t I Time City State Zll'Code me In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ¢ � � 0 PM 0 PM <br /> Operational Status Business Business Rolery <br /> (Fill one only) (Fill all that apply) f" � )YMp( <br /> � ..t' 5 � <br /> Q Active �� ® Generator C1tppr„� <br /> f d tt tr <br /> O CloseditdYed <br /> GPS LatitudeLLJ O Hauler <br /> ® Inactive <br /> » <br /> LLF Longitude – lanned <br /> End Use 1 Ctrttlt'e) <br /> O New Tire Dealer O Auto Repair Q Trucking Fleet Q Government O Retreader Q Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Service Station 0 Hauler 0 Agriculture 0 Shredder Other LT Wa - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation 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 <br /> Q O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O - _ <br /> 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - <br /> O & 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O Other: § ---- - <br /> Comments f } <br /> �' ✓� t(.y (---f YID(.( f[ Ji't !�y� _. L (_ , J '� ? �`,f,41(i'•c:` ''C= �f�i� — <br /> t t�.i� c�( ) i_ SFII �t/c co CCrtt �Uy�rll ''4 (' �J►4I(l v� � - (�- ..)A f ' <br /> _M11—A i E' ✓�'v1t:�Ur ��� ,,_ l�1V{:. . �C�C l� �i!.�_U t% +rt <br /> INN <br /> INSTRUCTIONS ON BACK Correct:I* Incorrect: '�( ( � ' ,°;,Wy 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />