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Waste Tire Surve Inspection Report action Report Number <br /> - -- - <br /> s State B California Survey Form - Page 1 $ - t� 3 <br /> �� CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board _.� _._ _.... -._. <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> TPID- EuInspection Type (Fill one) <br /> Site Suffix: JQ Routine Q Re-inspection Q Referral Q Observation <br /> -- <br /> Local }„ If Referral,choose referral type(Fill one) <br /> Identifier;: " ,tet l (�'�t I .Ifs" !%(;t y',.{ t.j.. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 --- - <br /> Inspected By Inspector <br /> Physical Address L - G: L ir`l [ <br /> Street / Q <br /> Inspection Date / �•} 16 <br /> L <br /> City c \ State ZIP Code Time In Time Out <br /> Business Rep l Title �j ®AM f _ I#AM <br /> O PM O PM <br /> Operational Status Tire Type `�, Business Role Storage Type <br /> i" (Fill one only) (Fill all that appiy)' (Fill all that apply) (Fill all that apply) <br /> T <br /> Q �Ctve-� Q Passenger Q Generator Q Outdoor <br /> m <br /> PS Latitude <br /> O Q Closed Q Altered <br /> G ', Q Hauler.'t Q Indoor <br /> D Q Inactive Q Truck (. <br /> Q End Use Q C <br /> Longitude - lanned ontainer <br /> Q PQ OTR <br /> - �.ter -�--+ ,, _.,,,,��� �s .,rn.,r�,� .� r.u• ' <br /> Business Type (Fill all th--at apply) T <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder (a) Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V i A ;HAULING AND MANIFEST REQUIREMENTS <br /> Q Q § ` aste Hauler9dTransport <br /> rans ort of Tires Q Notice Of Violation Q E esion <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years -- <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § - -- <br /> Comments <br /> j��t� ( <br /> I <br /> ' I T <br /> ' fit;` <br /> U(_ <br /> i <br /> Inspection Form Included: Q' <br /> -. . _.. , <br /> Comments Included: Q -- _ <br /> Business Rep's Signature Phone Number Inspector'$S.l, r�dture, Phone Number <br /> u "� <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �; I. 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> i <br /> I <br />