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.�_JR Waste Tire Su & Inspection Repod!! <br /> spection Report Number <br /> ■ ""` <br />� @86 State of California ^. <br /> CIW <br /> MB 181(New 04/04) Survey Form - Page 1 'i - 1 Q 1 3 7 7 i <br /> California Integrated Waste Management Board <br /> _ s <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> w ,� F '`'; z� ti u✓�,;Ya r:i'a i a.v�' ,' C ,,Fyd) �rari"1, ✓<4r� <br /> Inspectiold , ��d;w� � ' <br /> m <br /> TPID- f ` Inspection Type (Fill one) <br /> Site Suffix: Ce (0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local — If Referral,choose referral type(Fill one) <br /> Identifier: 1. ,r 1 jjy 1 f;. 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Physical Address �� J' ^�/,t <br /> I Street I <br /> Inspection Date <br /> City �`. t State ZIP Code Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> [QPM 0P <br /> L-Ll I ( j I <br /> Operational Status Business Role Storage only) Fir I r Type <br /> KK" Fill one a tf i; Fill all that apply) Fill all that ap l <br /> ( Y) ( N� �t� � � �p ( Pp Y) ( apply) <br /> Active 0 I' Yr` 1 ® Generator 0 Outdoor <br /> 0 Closed <br /> 7 r�ro)s <br /> (3PS Latitude Mia;�yl+w� t 0 Hauler 0 indoor <br /> O <br /> 0 Inactive 0 7ruct{:a�" y <br /> (' <br /> Longitude - I 0 Planned OTR End-Use 0Container <br /> tj F. , <br /> Business Tkipeu (Fill:all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 _ 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 <br /> M / m m <br /> 0 1 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 O <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 i 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 i 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 /> Other' <br /> 0 0 § - .._._--_-_ ._. _.__ <br /> Comments ' y <br /> C�: <br /> t f <br /> t` <br /> � _.a,�, 1� ,. i: t (�✓r:c.ci #�1 3 l i^ai <br /> ( _I <br /> r ,J <br /> r�j ,r�„ ' �`r�•( �.rr; <br /> 04 6a !� GC��iiPr�,•- �. t f ( i .j i ( -� ?.7., ! t ,-'• ,.n i - I Sf,• j j�� ,-►..,/,_ <br /> y I l <br /> Inspection Form Included: 0 <br /> Comments Included: 0 _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _.. 62081 <br /> INSTRUCTIONS ON BACK Correct:16 Incorrect: <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />