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., ns ctlNumber <br /> . .T Waste Tire S & Inspection Repor eon <br /> p_ -Report � <br /> State of California <br /> CIW <br /> MB 181(New 04104) Survey Form - Page 1 _: E <br /> California Integrated Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> F�us�ri� yl" Ins�tec#rgrl D'et�Cfls <br /> y <br /> Inspection Type (Fill one) <br /> Site Suffix: <br /> Q Routine Q Re-inspection Q Referral Q Observation <br /> Local <br /> If Referral,choose referral type(Fill one) <br /> Identifier: d f f^ y�f, <br /> A(.If , t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — <br /> / t/C ri�}y/ Inspected By Inspector <br /> L� t <br /> Physical Address ( rr Jft's <br /> Street <br /> Inspection Date <br /> City State ZIP Code J Time In Time Out <br /> Business Rep J P.� r�"`' Title _ O AM0 AM <br /> " rJV 1✓UYl Yr'lCi EEI . <br /> M___ <br /> 0 PM LLI LLJ 0 PM <br /> r Operational Statusype. Business Role <br /> ' (Fill one only) all that apply) (Fill all that apply) <br /> The Court (Who e/F� <br /> ® Active Passenger Q Generator <br /> .]7 T O r„ <br /> Q Closed Altered <br /> El <br /> GPS Latitude . Q Hauler <br /> t <br /> —"O <br /> Q Inactive <br /> Longitude — 1 s . Q Planned Q End Use <br /> Q New Tire Dealer Q Auto Repair 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 & Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS f <br /> V j A j HAULING AND MANIFEST REQUIREMENTS <br /> Q 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. ComplianceDeadline <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 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> - ,„•tt <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 0 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> r.i .' ' <br /> c:�ia�r= frJ�-c� ,z`'� ! dig% t rr�• ,. <br /> t F,— <br /> � a J - <br /> - <br /> Inspection,Form included Q k al <br /> Comments Included. <br /> Business Rep"s Signature. Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: I CXJ A M7 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />