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yy�!,,�!.Tire Sy & Inspection Repollnspection Report .dumber <br /> - - <br /> Survey Form v Page 1 ( 1 - 1 0 13 3 2 1 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part / BLUE OR BLACK A- Surve AC INK PEN <br /> i iii' ,� i ✓ W , ' / „°Ip�e+cbn Cleti~I>s.�.. '^r a' �,'�✓r✓k '4 <br /> TPID- + Inspection Type (Fill one) <br /> Site Suffix: �/ (, ,% _� ) ( Routine Q Re-inspection Q Referral Observation <br /> -- Q <br /> Local i� If Referral,choose referral type(Fill one) <br /> Identifier. Q CHP Q CIWMBQ Complaint Q Educational Visit Other <br /> Business or Facility NameT „ --- <br /> t I , <br /> Inspected By Inspector <br /> � r1!' <br /> Phys cal Address ��i ��I ) – FTu <br /> ^ I <br /> - -LI <br /> Street <br /> r� Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title Q AM QAM <br /> r PM O PM <br /> ry ail <br /> ;I Operational Status( r� t ✓ck p ✓ Bt�sness Role � � Yew"I e✓k <br /> (Fill one only) (Fill all that aPpIY) R1 <br /> #Active °`' <br /> �^ � .�" � �'"t Q Generator <br /> - Q yrt b'n�Ptyrq�,.,��r�'" %�,Gr �V` ✓' `y�x�'/�✓�x <br /> GPS Latitude Q Closed <br /> iN kit l' ` W l✓{u r7 . <br /> r r. tip a 10^"' a hfi Hauler <br /> Q Inactive F ;,g w) t1 ri p/ 'NsV6Mt ? F th' <br /> Longitude – Q i +� �' Q End Use <br /> Planned <br /> V <br /> _ .—..�__ _..._ a.i+.. .. <�I_��'lmw.✓d '.✓/�.�.1 .a sC .�_,.�r^w.r�u'��t"�., �..,._v r.w1..�...�u�t��'��r�n° r,n"rt�� tr•s�2,✓� bra tp Tf '. 1�J�� ry 1�FTT1.1 I � _[ ___10 <br /> .t.,e <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> QService Station Q Hauler Q Agriculture Q Shredder Other I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V , A t HAULING AND MANIFEST REQUIIREMENTS <br /> Q Q § � IR9Transport <br /> rans ort of Tires <br /> 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q 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 Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - — – <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § Q In Compliance - No Violations <br /> Comments i”n 1 <br /> :,: if e -7{"`_t t La'_ Lti)FLS f <br /> �l ti. ! •'tr) i l 1�'t j t'l G+ �_ __ /Uix l!1 t l i J _ f� J / 1( r?r Y_! <br /> ..Inspection Form Included: Q --- ---"- _-- -- — <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector'siSignnature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X /p V62081 <br /> X i A ?r�I � L- <br /> 07 <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />