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Yy�!te Tire Su ey & Inspection Repo Inspection Report Number
<br /> ifornia I I
<br /> oaxsll CIWMB 181(New 04/04) Survey Form - Page 1 ! 3 - 1 0 2 5 t 0 0 q
<br /> California Integrated Waste,Management Board -------:, -- --- -- -
<br /> Part A- BLUE OR BLACK INK PEN
<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix: I ( ( @ Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: 00
<br /> CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name_ Inspected By Inspector
<br /> 11'la'�(r^� J
<br /> Physical Address
<br /> �AJ k D`
<br /> Street
<br /> Inspection Date
<br /> City 7P I State ZdP Code (' Time In Time Out
<br /> Business Rep Title O AM O AM
<br /> 0 PM mLLJ 0 PM
<br /> Operational Status qt Business Role �F
<br /> (Fill one only) �, (Fill all that apply) rf6it + �+
<br /> a
<br /> a .T L-r ® Active ti ,P� ;f Generator + s a y yYYfb"
<br /> 0 0 Closed it a rya d(` 7t� � 'Fyd4 R l)4
<br /> GPS Latitude EL I j
<br /> V µ" �>r �'�.MGtG �^,aI � Hauler
<br /> 0 Inactive
<br /> "
<br /> End-Use
<br /> Longitude — � 0 Planned ,r. �y , ��r
<br /> rF
<br /> H 5:. r
<br /> 0 New Tire Dealer 0 Auto Repair (* 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 0 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 /> =� 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 / m
<br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<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 0 In Compliance - No Violations
<br /> 0 Other: § _.._..._.. __..
<br /> Comments I I
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<br /> COrtlmenta.)rIG"ISIr
<br /> INSTRUCTIONS ON BACK Correct:* ;incorrect: l X A M P ��� 62081
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<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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