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Waste Tire Suey & inspection ReporInspection Report Number , <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 l Q 0 6 4 3 1.. <br /> California Integrated Waste Management Board J - - <br /> Part ASurvey BLUE OR BLACK INK PEN <br /> +, <br /> ,� <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: T <br /> (D Routine O Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CIWMB Q Complaint O Educational Visit O Other <br /> Business or Facility Name' Inspected By Inspector <br /> Physical Address 1 { <br /> c <br /> Street Inspection Date 77 <br /> EA f") <br /> City State Z/P Cade Time In Time Out <br /> Rep Title 1 <br /> Business &AM Q AM <br /> L! � � QPM � ' �.. QPM <br /> Operational Status (` "y Business RoleNOWT-7:[] <br /> ; <br /> +f (Fill one only) 1y (Fill all that apply) <br /> ' r� <br /> ..; (D Active � ,Generator <br /> s <br /> O Q Closed ti`r (`�a r"�" <br /> �r <br /> "P "ude O Hauler <br /> D Olnactive <br /> 4 b Riled r <br /> Longitude — Q Planned r / End Use KI i <br /> : il a,� �iU�".art ';yy,:::�6 r" s ^" "� � +t"r'�r✓ �il Yrr" ��"r"il� �'"t �,� <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government,' 0 Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 0 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 A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q 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 m <br /> I I / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB W <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments 7 <br /> r <br /> c <br /> f t —'� 1 y r F1� / <br /> CX r c /il' ` - � ` t /1F ^v — <br /> f�nrv"'�d' 'aha"; f r �°ak par . ,�,��' + �,Yr 2 ip a�•� ,r St"�x`,. ,u � .r n +,�x++„ ,�,: o- .- <br /> 4. a""dy�, <br /> QslnessR$pS�'Sy ; r�`x .tl "W,�, �`"; l�.r ,..,, x....:w ..b�,,t„tsrp.L..,.� ":� r ;+ l'�' a� ` .��,r. :�a. �.Y>F✓' <br /> . ... <br /> r„..-,. <br /> i+ 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect , ' r r fYl 1 ' <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />