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Inspection Report Number <br /> Waste Tire SLey & Inspection Repor _ ■ <br /> H.' S State of California 'J . - A P'S 01 <br /> Survey Form <br /> CIWM8181(New04/04) Page 1 1 0 L <br /> California Integrated Waste Management Board - ---- - - --- <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Bu&�nes Wnr lw°dd nrc> r /krpt° P �iA � vyr ��� N <br /> a 3 YtJ e <br /> TPID- 1 ) l Inspection Type (Fill one) <br /> Site Suffix: 1� �) ! C_�uI �) -, Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. ;{k `,t i / .L,. 41 y.: i 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 4 , <br /> Inspected By Inspector <br /> • <br /> Physical`Addre"ss <br /> Street ^' <br /> Inspection Date -� <br /> City State ZIP Com Time In Time Out <br /> Business Rep Title 0 PM m m 0 PM <br /> I TiL <br /> 3r <br /> r r era <br /> Optional Status a +� ,� , Business Role � +r <br /> r«�rrr-�,�Yr t°"•[ �Wf t:r t +'^� <br /> . a (Fill one only) (Fill all that apply) <br /> ire aunt <br /> .. <br /> Active Generator <br /> 00 Closed <br /> GPS LatitudeED - E Vutnur• !-mar0 Hauler <br /> lrt*.wa r r ��fr3�M1��H r1n' <br /> /f <br /> inactive <br /> Planned <br /> Longitude — 0 t t � I�%� End-Use <br /> g nv� :wlk�)�� <br /> ,.r/.., <br /> 0 New Tire Dealer 0 Auto Repair I(& Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O OPRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> I <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / [T] <br /> / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 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 0 Referred/CIWMB Enforcement <br /> I <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No violations <br /> O O -- <br /> � <br /> Comments <br /> r . <br /> F'' 1 rw'n�., v a� i ..; rl+ .nr a ' ,� .ti r "r ,W r �'r +'�wn'r Sf r a^Y�a+ +fir ew �+r v v�$r +�rr yr„GFS/ l r:. /''p r ' k r�Y✓n y 'k v f a '^ <br /> �tlspeCt1o11 I`t��� In�ir��ed, � ,w "Y r` + � +''/ r ri t �� �”�}v "+t P Yh y �giti l;ar � ��/ ,t ✓ rY' y"y��^r r✓r 1 � l u :X t � 1 r � nr t <br /> INSTRUCTIONS ON BACK Correct:10 incorrect: X � V A � 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® S <br />