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_ Waste Tire Su�, & inspection Re or <br /> ,Inspection Report Number <br /> � <br /> =` CIWMB 181(New 04104) <br /> Survey Form - Page 1 -_ -� <br /> aan S y g - BLUE OR BLACK INK <br /> California Integrated Waste Management Board <br /> Part A Survey PEN <br /> ITPgsa C a ¢�F 2 " a"d r vv, •;'attapet3tiAtt C1eta41S <br /> ID-- _ �. — Inspection Type (Fill one) <br /> Site Suffix: O Routine I&Re-inspection Q Referral O Observation <br /> Local �— If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB O Complaint Q Educational Visit Q Other <br /> k,. <br /> Business or Facility Name Inspected By Inspector <br /> " <br /> Phystcah Address <br /> Street l <br /> Inspection Date <br /> City State ZIP Cade Time In Time Out <br /> Business Rep Title � AM � AM[T] � �0PM =1L1] 0P <br /> !%r 7t t_ i <br /> Operational Status /rl Business Role <br /> (Fill one only) � ( I�I � ► (Fill all that apply) 6,° � fi� <br /> Active ' ' � `✓ ' ory� <br /> Q V <br /> a„ e � r �+a'• ✓''a Generator µr r" ar t v�� ✓. <br /> � w w '� ✓m"t� d"s � jj^�p 2 <br /> INH/A NM 7 K 1,yW �l"N�i4G: A�/✓� R�/ <br /> 1-10 <br /> O Closed <br /> LatitudeFT <br /> GPS <br /> ��1'r,, i ✓�� ✓✓ ✓�, p�: I, ✓w�` �✓ <br /> fa ✓ p �lt �� �tMr <br /> — 0 Inactive Q Hauler� � P,� t�"J�', i�� <br /> Longitude O End-Use � �✓ <br /> B;Isiness Type: (Fill all thatapply)m; <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler O Agriculture Q Shredder O Other <br /> " I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> rV A HAULING AND MANIFEST REQUIREMENTS <br /> �Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M <br /> 14 CCR 18459.1 a b)(c)-Tire Program ID Number from CIWMB m m <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV arEXT) <br /> Q Q 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 Q Referred/CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators `n <br /> � ' fiance - No 'Violations <br /> O O Other: § <br /> -------------- f' f <br /> Comments 1410 <br /> Inspection Form Included: <br /> Comments Included: 0' <br /> Business <br /> .Rep's Signature Phone Number Insp ector's Signature Phone Number <br /> X /P "� 62081 <br /> ■ INSTRUCTIONS ON BACK Correct: Incorrect: <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />