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Waste Tire Sy & Inspection Repor InspectionReport Number <br /> - - - -- <br /> ���� StateoffCalifornia - - � I• <br /> CIWMB 181(New 04/04) j i/�f 1i� <br /> California Integrated Waste Management Board Survey Form - Pa je 1 { 1f t`j ''j' <br /> Part A- Survey BLUE OR R BLACK INK PEN <br /> rr <br />} TPID- Inspection IInlspection Type (Fill one) <br /> Site Suffix: ! �_�� - Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier. 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> or Facility Name <br /> Business ' Inspected B <br /> p Y Inspector -% <br /> Physical Address <br /> , r <br /> I <br /> Street E.I—_! IF7 <br /> / <br /> Inspection Date / <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title M Q AMM AM <br /> V1\ � r QPM F <br /> � QPM <br /> SIR <br /> Operational <br /> erational r Sft^ar t:usynC <br /> Business Role ole <br /> (Fill one only) (Fill all that apply) <br /> 0 Generator <br /> Q0 Closed <br /> GPS Latitude 0 Hauler <br /> fff p OInactive <br /> .�^♦��>f�1),q����;tt��r�)�r�r��9/"���t}ru�/�"r�rt�7rq/�✓I pf,r/g,f�r1i7if <br /> r^�r�a�"i1��r��fyr�C���sW'/t�✓ <br /> Longitude 0 Planned 0 End Use <br /> 71, <br /> r <br /> r <br /> � <br /> � <br /> i <br /> Cf Biu <br /> -... _., •....., .._ � ............ .e ._,.....,,,:;�,ha —�rr �<,�,4y1,�"?.".,�° �`.✓_u'* /�a.1/�.�irv�r_r.:7� 1����;•M.w�n�?�, ��. �,'�.n,,,>�-x,""f°�,.`�,ua h:.'.�ry.W.�yb��y,�;a�' �. <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 /> PRC 42951-Waste Tire Hauler Registration and Transport of Tires Notice Of Violation 0 Extension <br /> O A ;HAULING AND MANIFEST REQUIREMENTS <br /> V . <br /> § 9 P <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 <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 I 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 ; <br /> -}i(; l;t�U :+A�:.�- f G[-�• t-'l��� � ;Simi. ,::1 �tr ` - �'`/I - - .�_r ' �4f� <br /> -Tl(( <br /> Inspection FO <br /> A r , <br /> i <br /> Comments included: 0' <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ _ <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X Gf, Y 0+ f 1 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />