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■ Waste Tire Su*y & Inspection Report�lnspection Report Number ■ <br /> Report __ <br /> rni State of California Survey Form - Page 1 1 t 4 - 100 '0" 734 ; <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> — <br /> � '� t—�.M�r�.�.:"_ �• �^�.c��%''Y�� .r ~»M .r-:,b a�,�°t.uk�„,a�.„ H � ��`" �y"t �,"'��S"�,�� <br /> TPID- - Ilk] <br /> Inspection Type (Fill one) <br /> Site Suffix: Raotine Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> . p Y Inspector <br /> ---—--- ------......... - — 1 <br /> Physical Address <br /> Street -- _ <br /> - Inspection Date <br /> City -- --- - State Zip Code Time In Time Out <br /> Business Rep Title AMAM <br /> I_ l k 0 PM __ '- F" QPM <br /> _ lu- <br /> gt _ � <br /> d Operational Status Business Role �� ( ew <br /> ( (Fill one only) (Fill all that apply) tlfa (,/ 'k( <br /> R 0 Active 0 Generator <br /> GPS Latitude O 0 Closed , <br /> u�1Fa <br /> O Hauler ` <br /> O 0 Inactive <br /> Longitude - ` End Use <br /> y <br /> • 0 Planned <br /> r awi2 kr+r 4d GdN na!rr �:r,' rl t� aay 4 r <br /> .:,. ;:m a .-✓ °r i,^ "' '�r w r ,.7A.r" n�r�,+ N, y a y,w" o,x., rr a i' �, 2•'y , sa <br /> r; ...1/rn r ,?�'7a i r �r, ��1 �"..�:: �' "16 r4rt � r&Wti' ',„ r=•w 9" �J% l r z. <br /> �r <br /> 0 New Tire Dealer 0 Auto Repair Q Trucking Fleet 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 /> VV A j HAULING AND MANIFEST REQUIREMENTS - <br /> 0 Notice Of Violation 0 Extension <br /> 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 m <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB I I I <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 Q In Camptiance - No Violations <br /> 0 0 Other: § <br /> Comments - <br /> t <br /> - _V <br /> r, <br /> r' <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I , P LT � 1 2" 31 62081 <br /> White Copy:CIWMB Yellow Copy:Operator "' Pink Copy:LEA <br />