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Waste Tire Sulky & Inspection Re or Inspection Report Number <br /> ■ '.:.C5�31.- St ate of California 1— .-_-. -_-._ -_.--- .__ ..... ....... ■ <br /> .zea - ' <br /> CIWMB181(New 04/04) Survey Form Page 1 1013649 <br /> California Integrated Waste Management Board _,. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I pi�' 11'IlS`pC3t tl�' it ya"2' �'7a eli "'h`fit ati31 aN'?�"oi���i g, <br /> } t1i Mhln <br /> TPID- / E / + I I _ Inspection Type (Fill one) <br /> Site <br /> Site Suffix: <br /> Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: `; r.7 1C 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - - <br /> Inspected By Inspector <br /> L1 7/) <br /> Physical Address A,j t- <br /> i <br /> Street <br /> i Inspection Date <br /> Time Out <br /> In _ <br /> City - - State�7_lP Code Time .._ <br /> Business Rep TitleQ AM O AM <br /> O PM � PM <br /> NIGER 10,IN;! r61 Operational Status w r, �� Business Role ' bre� <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) 3llt ( 1fa (51y <br /> LALI& Active ® Generator�,w� E���� � 'r ti ��'�d�� Kfuria fr6� <br /> as a(�"d�,m t"* ✓ 363 i Y{ ? r u l �+, <br /> J—]0 <br /> 0 Closed <br /> GPS Latitude DAC � y ya,treti �a/3yM( yS�)f+�r, <br /> ( "Qy�w' r�H6tlx ti u, 0 <br /> rpt Hauler lu (34' �� as a6ai 1 <br /> Inactive 7a l�' ('1�3u"3 tiPzyn{ <br /> Longitude - 0 Planned �( r � )�'� 0 End Use <br /> 6/� r�rr�a3N�tli��A rrpWpw��i 36a1 �66 ����ry'l"3 mttq,y# <br /> . l r r ""1(r ✓gyp C n 9w.� T <br /> M.°+.r .e y;.�.,a.k3.:�`^ mau,«r ,.. .�_- ..._i. *i13 .✓.Hf?3 _i N21 <br /> ® 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 /> - ---- --- 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 IE / m / 1:11 <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 [ j ; <br /> Qe <br /> '^ �.f /�^.tee-i-�#���� (.'G��-?�,-' jl.C/<� :t:1�=e:.. �� _'z-p' J.z� •��� ! � r�� � C�- <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:01 Incorrect: X :u. �, 1 I v'i 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operalor Pink Copy:LEA ® ■ <br />