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r N s ion u _ <br /> Waste Tire Su&y & Inspection Report aInp Report o t mber_- -_ � <br /> ■ s3T8E State of California `J�j /'jy �f''ly :d <br /> California Integrated Waste Management B rVey Form - Page 1 1 V 1 2 '+./ 1 -' <br /> Part A Surve St <br /> CIWMB 181 New 04/04 <br /> Board y BLUE OR BLACK INK PEN <br /> _� y " +_ Y M r I'a rt 4 r it x rtnrw ✓} k+ i t n I�eta►�I r " M r ni'+ A <br /> PI <br /> TPID- I t Inspection Type (Fill one) <br /> Site Suffix: �� C! tJ �j .; I--' (gill Routine Q Re-inspection Q Referral Q Observation <br /> Local a If Referral,choose referral type(Fill one) <br /> Identifier. t �, ),,f�q i t �` ( 1 j i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> P— y is DELZLILd f <br /> Phal Address <br /> - — <br /> Street <br /> ,. 4 r( Inspection Date El <br /> I ( i'.. �`1i i 1 <br /> City State ZIP Code Time In -I0 AM <br /> Time Out <br /> Business Rep qq Title O PM E0 . O PM <br /> M MKS Operational Status r e t Business Role <br /> (Fill one only) 1rd"rt (cel ) (Fill all that apply) <br /> w=n <br /> `'� <br /> ® Active Generator <br /> Ram <br /> Q ClosedIfit�X +7;, <br /> GPS Latitude I I ' ==0 <br /> ki 4 Q Hauler <br /> GPS Q Inactive <br /> Longitude — Q Planned ' 3a „q' ��' Q End-Use <br /> !! �' ) rn dy'%r^to rr4 tYw�dr <br /> ' '19Ih5 %T p, �yyFlll A,I�L ry rr '"..r k^n r t t b: a 7V✓'f1 6 d1 r r a 1%,%%Y%,yrFi;Y R)u�at s1 9r� irr w ✓n ,bpr ,V r, r y 1 �” . Y <br /> ? .,*,.! �.,,-.v.. R....1�a%".� .'_.. .... ,i:. rib !.r,..n..:•, -:w•_.�..v�.c 1 .1-..: .,{.,u-�.a ,� ." ..,1.y.,i., 1.3 �_����._d ,/ +rt <br /> Q New Tire Dealer Q Auto Repair ( 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V q HAULING AND MANIFEST REQUIREMENTS <br /> Q QQ Notice Of Violation Q Extension <br /> PRC§42951 -V,Vaste Tire Hauler Registration and Transport of Tires <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 <br /> Q rQ 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 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years l a <br /> Q Q <br /> 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 Q In Compliance - No Violations <br /> 10 O Other: § <br /> Comments <br /> f +C.0 �11r�_`t� (0y' <br /> Yc 16-1 vi &Ioa-i It f VI(' �t <br /> i <br /> u dp <br /> rr' <br /> ��,��� �"���w�"���,n�`@�:ryti�kl�" Y ��;�Stn�SS'.r, �p'�`w.��i�t� �„�ryTP,, ,r`Y�,�.�,"�n,�'tl�'�W�`�� i= �'`�yt� 'r iv ;7, , YWY."tn,'.,, J ii✓�..;� S ' ��?tS, ..y�,. <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: N <br /> L E 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />