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s ection Report Number <br /> Waste Tire Sur�y & Inspection Report �_ � p_ p -- _ <br /> California La State of California Survey Form - Page 1 # 1 1 0 1 3 2 0 1 <br /> CIWMB 181(New 04/04) <br /> is Integrated Waste Management Board ------ - <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> refa M w'.o., <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 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 /> Ph glcal AddressLi S I <br /> — <br /> Street Inspection Datej5j <br /> Citi y --' State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> tif" --— • = O PM -- 0 PM <br /> Operational Status <br /> , Business Role r l r <br /> (Fill one only) (Fill all that apply) it (id l tai <br /> ® Active �I � � "r`� Q Generator pa4I1ibfr; <br /> i <br /> '' r rv11 9q ry yri ,w 7 t.�,rIX�pYI. <br /> ( IO 0 Closed <br /> Latitude HaulerGPS 0 Inactive <br /> 0 <br /> "Longitude Planned @ End-Use <br /> ^'1 <br /> r" <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Q 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 /> � <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> I p'' <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements Date <br /> I H] / []] Ill <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 Referred I CIWMB Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers i 0 <br /> Q 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 Oto Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> lr�spelot4'Fnhm Included 0a ( / <br /> r. + ,,y yy.r ✓G� r .! r:r� ? / a � r r +y P S � f rl k� f,,� , .. <br /> _Biisuiess Rep's Signature PhRn 'N� ber " 'yt^r, s c#di° .„ Rhone Number _ <br /> X62081 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: V �� <br /> Copy: - - ■ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />