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.. . .:■ 4—MIL- _w. ,JW .- _:sa 'Facie. .. 4rim- <br /> ......q <br /> Waste Tire Sur4y ' , Inspection ReportI tion Report Number <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 1 9 . 10067961 <br /> California Integrated Waste Management Board -_— - -_ <br /> i.Part A- Surve BLUE OR BLACK INK PEN <br /> TPID- + _ - m Inspection Type (Fill one) <br /> Site Suffix: I 3 0 �3N (D Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local f^ If Referral,choose referral type(Fill one) <br /> Identifier: t'lr� QQ (/t-1,r\_j 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address I J � ! 101 / 1 , \Tewl - <br /> Street <br /> floo W. Siree--i <br /> c _ Inspection Date 9 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title // ® AM C) AM <br /> P^ 0 PM / ? �� O PN1 <br /> Operational Status Tire Type Business Role torage Type <br /> Tire Count (Whole/PTT , (Fill one only) (Fill all that apply) (Fill all that apply) Fill all that apply) <br /> ® Active 0 Passenger 0 Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> -- O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use Container <br /> Business a at ap <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 /> ® 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 0 Notice Of Violation 0 Extension <br /> 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 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 I Other: § - <br /> Comments 1 <br /> f.��^tl► 1 hi 4A f/I(oll '!> t `i dC, �d r.r rU f�GW1;^. ( via !, nCfP� 1: till's/ CtCct!-t <br /> ,P�1 IOHV 'VD/L4rVjE -�Op *rlQ/y) Arr S . WC,`.��f ftrp S C-EVe 1 Looi ktaoae.i:( _one <br /> y /J C4 _ 11rY t b'bp . jt) want iP`.�i a ✓CLd c 1� �c � `��i i l t A-1 e-.. <br /> { 1 I(, , ,.0 C I('0 Y) <br /> Inspection Form Included: <br /> Comments Included: Business Re 5i <br /> 0 Rep's Signature Phone Number Inspector s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X F X P <br /> �, . 14 P I L I El 111213 1 <br /> 6208131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />