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■ Waste Tire Su y & Inspection Report inspection Report Number <br /> 5a'7. State of California <br /> ,ate CIWMB 181(New 04/04) Survey Form - Page 1 i 1 3 10 0 0 4 3 6 <br /> California Integrated Waste Management Board <br /> Part A, -Surve BLUE OR BLACK INK PEN <br /> - <br /> *f� <br /> a f <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: r L <br /> E51- Routine O Re-inspection O Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CIWMB O Complaint 0 Educational Visit O Other <br /> Business or Facility Name <br /> -_._ Inspected By Inspector <br /> Physical Address <br /> t <br /> Street <br /> Inspection Date EE <br /> / H] <br /> / E-ALIDI <br /> - Time In Time Out <br /> City State ZIP Code <br /> Business Rep Title Q AM Q AM <br /> / Q PM _...._ ' 0 PM <br /> < ,hyr\C' l.L�_f A,n . Operational Status m !'�f B <br /> # usiness Role 1 <br /> (Fill one only) (Fill all that apply) <br /> Q ActiveIla <br /> Q Gene <br /> HaulerrGPS Latitude Tr� 0 Closed <br /> ator P�s'lig�y <br /> �rytr <br /> � <br /> Q Inactive <br /> Longitude - O Planned t �i ' n' O End Use CI � e<rl <br /> t <br /> " �r,,,d <br /> .'' ..P <br /> 'Ott <br /> ,. , �_ ._��. ►.,:�„W_�,w_��4 W���-..��„�wy <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet O Government O Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body a-, Car Dealer Q Collection O Crumb Rubber <br /> O Service Station 0 Hauler O Agriculture Q Shredder O 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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§ 18459 Responsible Entities Complying with Manifesting Requirements Date <br /> 0 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 1 Q 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 I CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O O Other: § _� --- -- — L-=- <br /> Comments 1 <br /> i,{ ;n 1 cI '.r'\� �r, in- f-fk A <br /> ' 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: i w,tir�, I 1 .2 .3_ <br /> ■ _ : ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />