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Waste Tire SuAy & Inspection Repor, p p <br /> Ins ection Re ort Number <br /> ka <br /> State of California CIWMB 181(New 04/04) Survey Form - Page 1 -1006 Y f <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE.OR BLACK INK PEN <br /> Inspection Details <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: a t "'(t ( { i it r r 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name l <br /> �. Inspected By Inspector <br /> Physical Address - i-k! r I rr <br /> ( `t r <br /> Street L / _ <br /> i C1 - Inspection Date <br /> C'. State ZIP Code Time In Time Out <br /> Business Rep Title Q AM /I Q AM <br /> O PM `r! 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PT <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � <br /> Q Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude !I 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> 0 New Tire Dealer 0 Auto Repair 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 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation 0 Extension <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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> h i;l.•tJ li rlfrP r .. tGi� .� 1 + C {.(v )INoi,jI <br /> (�C�'` JFI(Fid litKl��{. 11 1 � jriLi f�yl(rL_�11 Qt �s �� N/s � t i-"!- tC'f` i _ ,, . fl <br /> 1 I V• <br /> (111- OX (;r1C,,, �t �k-- jot - Vlle i r `�rfuc�'� th Lj0fd AA, 4" -' VIS v+./ (."ton <br /> ✓��. If. Cl " = ill f'isl di i f . - <br /> Inspection Form Included. <br /> Comments Included: 0 - Wgnait,, <br /> Business Rep's Signature Phone Number nsp ctorsPhtimber <br /> �r A <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X "v � It',, I Z 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />