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® Waste Tire Su ylnspection Report* tion Report Number ■
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<br /> State of California
<br /> Survey Form - Page 1LL2 . 10 2 5 0 0 9CIWMB 181(New 04/04
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<br /> California Integrated Waste Management Board --- --- ----
<br /> Part A Survey BLUE OR BLACK INK PEN
<br /> 4r 161 ✓%k r �" /r sell"a l Fyrtr ,� Y ,"" ✓»:. .M.�c�.,.. .„
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<br /> TPID- f f `/ I -, t Inspection Type (Fill one)
<br /> Site Suffix: Y I _ I (41 Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: _-1 �(. .,` (� i✓ f ,,.y �, { 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name Inspected By Inspector
<br /> 01 I t t ( �t r VIr LLL i _ -
<br /> Physical k4ddress r I l° i' , L.,
<br /> Street _ Inspection Date j;• ��1—.1 / _,
<br /> City _ State ZIP Code Time In _ Time Out
<br /> Business Rep Title _ O AM AM
<br /> y ... 0 P � � QPM
<br /> t' ��t t l {) �, t�1 '�c;� �I� tG, - —per r ,m ✓
<br /> Operational Statusyi� r {r Business Role �s r e
<br /> (Fill one only) t11itp )i (Fill all that apply)
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<br /> 0ACtIVe �Is�ltger 0enera
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<br /> -� 0 closed
<br /> Latitude
<br /> ��� elerd
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<br /> _._ 0 Hauler
<br /> 0 Inactive
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<br /> Longitude0 End Use
<br /> - 0 Planned I ,- ars ✓t ,,
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<br /> '@, .. r.. �u✓:L ...s ,.�.. ��'ue'^�
<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 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 /> - I 0 Notice Of Violation 0 Extension
<br /> 0 0PRC§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 /> R 18459 -Responsible Entities Complyingwith Manifesting Requirements Date`
<br /> 0 0 14 CC § P 9 q M / FTI / 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 forNOV'orEXT)
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<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 0 Other: §
<br /> Comments
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<br /> 62081
<br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: �' ' Y'"1 lan I C
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<br /> Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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