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Waste Tire Su#y & Inspection Reporinspection Report Number <br /> 61-211 <br /> State of California - - <br /> CIWMB 181(New 04/04) Survey Form - Page 1 1 - 10 1 3 4 0 2 <br /> California Integrated Waste Management Board <br /> Syryey <br /> BLUE OR BLACK INK PEN <br /> Inspection Details <br /> TPID- Inspection Type (Fill one) <br />} Site Suffix: Q Routine Q Re-inspection Referral Q Observation <br /> Local / ,t If Referral,choose referral type(Fill one) <br /> Identifier: ! <br /> ><(, (,r.(/� � � ,, ,, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( s` - <br /> Inspected By Inspector <br /> �Plhysical 'Address DR — -; ( � �� i' ,_ <br /> Street <br /> f 1 /-�, ..-, � Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title AM AM <br /> til Q PM �� O PM <br /> Operational Status W + ) h r1 w Business Role ) �r"4 <br /> . A (Fill one only) 1(' tllyf )r } �I y (Fill all that apply) <br /> T COU"It PIuAlholelPTE) <br /> � <br /> Q Active � ���f Generator �� 1 (rtYl ' <br /> Q Closed ( <br /> PSLatitGude _TTT_ <br /> Q Hauler <br /> 0 <br /> Inactive <br /> i <br /> Longitude — Q Planned QEnd-Use <br /> ���, fi ,r +(�")+��� <br /> r.� G,.:. <br /> i v,:�✓:. a•"-' r v ✓; -: ,:w � ✓t,rr :!T , tiw4 � 4 "' f�,t <br /> 1 <br /> 5 � �' Ott r d">n + Y� r i +�f: n+rr sFl� Jr"a�� .a il✓`J 9 k y'f,.grey r"3�9;.�"ah vil� �w°../w1 � �$�rxt �' "' u r r��+:W to � � <br /> ....:. .. ..,.,,.,<. ......_ ...,, r. v.�...A.-._... <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 1A ?HAULING AND MANIFEST REQUIREMENTS <br /> - <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 / 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 (Required for NOV or F-XT) <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 7 i <br /> l II r' (�f <br /> I 1� I, r 1. (i, _1 � t( ` (;1 ( f1f � 1{"✓lam f cJ VI� .�'() vk, <br /> Inspection Form Included: Q' <br /> Comments Included: Q' <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> t' 62081 - <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X � .�,i A IV.,r, <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® S <br />