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Waste Tire SurOy & Inspection Report onspection Report Number <br /> State of California ■ <br /> ®IZ6u.w CIWMB 181(New 04/04) <br /> California Survey form - Page 1 - <br /> ' Integrated Waste Management Board <br /> Part A Surve BLUE OR BLACK INK PEN <br /> Illslne&$PrOfllo f .`: `- t ry� y�� rF i <br /> TPID- l , C r._ N Inspection Type (Fill one) <br /> Site Suffix: ! � >' ] I U /L�L (� Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local i -- 7 - — - - - If Referral,choose referral type(Fill one) <br /> Identifier:( /'t f �-i ,� ( , : J t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name --11 -/ - <br /> Inspected By Inspector <br /> t . 1 <br /> Physical Address r - L, L_L1 J <br /> F-7, I <br /> Street ��— <br /> + Inspection Date ) <br /> City - State ZIP Code Time In Time Out <br /> Rep Title QAM <br /> Business 1= : F-E]OAM <br /> ll m <br /> 0 PM 0 PM <br /> Operational Status r <br /> p ,,, ui •.r Business Role 'Storaye`Type <br /> (Fill one only) (Fill` ll thafi app)Y)`i (Fill all that apply) "(FttI all that apply) <br /> 0 Active (�"Passetier 0 Generator 0 Outdoor <br /> 0 O Closed 0 Alterod <br /> GPS Latitude 4 , p-MM -LL� Q Hauler (� Indoor <br /> III III ( ��jj --�D Inactive Q T u6ik <br /> � <br /> Longitude - ? _� �� � 0 Planned ,(�pTR 0 End-Use Container <br /> Business Type (Fill all that apply) <br /> - -- — -- _� <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 (a Other , G <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFORCEMENT STATUS <br /> - _- _ <br /> V ! A HAULING AND MANIFEST REQUIREMENTS <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 / m / IE <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> J <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMBEnforcement <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 0 Other: § <br /> l <br /> Comments 1 1�� C)d l <br /> k';< ��'t� (:l,- -t tl - ��'I J � � l Y' f �f<! > I _ , <br /> 7 1_, <br /> � <br /> ;�u:„1 m „ r✓'. rµd�Vrb ' ...i <br /> tnspe hiKt? a ,hel" a , r I <br /> Corm ants Included,' - <br /> Busmess Rep's..Signature Phone Number', Inspect s S►grrature Phone Number <br /> -w- <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect: �,, =111J i � _ <br /> ■ White Copy:CIWMB Yellow Copy:OperatorPin Copy:LEA © ■ <br />