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&y & Inspection Repor Inspection Report Number ■ <br /> � ka <br /> Waste Tire Su�State of California CIWM6181(New04/04) Survey Form - Page 110 0 6 4 4 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> 7TPl - FI <br /> Inspection Type (Fill one) <br /> -J Site Suffix: I ;I ;j c 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address t ' - J <br /> Street. � I - <br /> Inspection Date <br /> E12- <br /> City State 7_IP Code Time In Time Out <br /> Business Rep Title <br /> 0 P ' 0 P <br /> Operational Status rte r t1 Business Role <br /> 11(Fill one only) nt�� MI 7 ; (Fill all that apply) <br /> 0 Active a�rrX ���3r+ps. <br /> tr( [4tiacl'�� r ,,tiy." 0 Generatorr� � <br /> w`6wi� r ,a�+;� °✓r �w w6 r-. r�r rr r, a r <br /> PSLatitude 0 Hauler <br /> 0 Closed <br /> Ginactive <br /> 0 <br /> ar1, <br /> 7• <br /> rAfff6��r'+y„ sit <br /> err '�T� T1w' 0 End-Use �sbr� <br /> Longitude 0 Planned ,' ' ,' �a <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 - 7. <br /> IV <br /> A 'HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 I 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 0 Other: § <br /> Comments <br /> f <br /> r <br /> INSTRUCTIONS ON BACKL Correct:; incorrect: .N , ,I'�Iq P 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />