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Waste Tire SuAby & tion Report Number ection Re <br /> ort <br /> State of California <br /> °' ' CIWMB 181(New 04/04) Survey Form - Page 1 ( 8 - 1 0 1 3 4 1 2 <br /> California Integrated Waste Management Board _. <br /> Part A- Surve _ BLUE OR BLACK INK PEN <br /> prxtt(Itfi(� � <br /> . ��.u_., W_� <br /> TPID- f Inspection Type (Fill one) <br /> Site Suffix: (j) Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local t r- If Referral,choose referral type(Fill one) <br /> Identifier: RRR 9- <br /> -- _ <br /> SIXt r:�,�L 4 �St f•, f �� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 71 <br /> Physical Address <br /> i - -- UJ <br /> Street.._ Inspection DateCA t <br /> City State Zip Code Time In Time Out <br /> Business Rep Title y O PM O AM <br /> (a <br /> _ O PM <br /> Operational Status Tire T Business Role -Storage Type <br /> (Fill one only) (Pdl all that ` / (Fill all that apply) (Fill all that apply) <br /> Tire Count(W11,616 TE) <br /> (Active Pnss ? °+, ( ,Generator 0 Outdoor <br /> GPS Latitude O 0 Closed Altert� t " <br /> (Hauler 0 Inciaor <br /> active Ttuck <br /> 00 Inet. <br /> r <br /> Longitude Planned D OTR •L t' 0 End-Use 0 Container <br /> Business Type (Fill all at apply) <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 Q Hauler 0 Agriculture 0 Shredder 0 Other <br /> - I <br /> Part B - Inspection of Waste Tire Dealer Generator Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 0 <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 <br /> 0 In compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> , <br /> , / '.: /t /�1.1 ;, � � ,i/ '!i? i.f I,i .:..( �� �I F- �t '~i �'...I �"- },rt .-, r�_ t.Cr-t' � �✓ f <br /> l <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:® Incorrect: ,/ 62081 y, I„ 1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />