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Waste Tire Su & Inspection Reportpection Report Number <br /> State of California I <br /> CIWMB181(New04/04) Survey Form - Page 1 ° 1 8 - 1 0065971 <br /> California Integrated Waste Management Board - - <br /> Part A Survey BLUE OR BLACK INK PEN <br /> fist a- ""'2' visa' +« ^� du ra n 'Y' r 7 riP' wib mrr➢,� J r,h fa d <br /> ;'�ili!fio �fK � �r� �"�vi�tr,i 'M"�y#"`"i�✓r ., �,� ~ t�"E�', i"`""i� n r f c�'r�rrr s�pr�wv� ~",r k iya� <br /> n Details <br /> .... - <br /> TPID- t ,,.� - Inspection Type (Fill one) <br /> Site Suffix: + �' S t Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: G., �. ��,..._ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address / - / 4" <br /> Inspection Date "7 <br /> city - State ZIP Cade Time In Time Out <br /> Business Rep Title [E : CE O PM O AM <br /> 0 PM <br /> i Operational Statusf ""s/y1 Business Role Storage Type <br /> (Fill one only) (Fl (1� ( � (Fill all that apply) (Fill all that apply) <br /> ® Active F"11106er Q Generator 0 Outdoor <br /> 10 <br /> Latitude m Closed <br /> GPS AItMred <br /> �� � 0 Hauler 0 Indoor <br /> D 1 0 Inactive 0 Truck <br /> Longitude 0 Planned (( 0 End Use 0 Container <br /> 01111 <br /> 3 New Tire Dealer 0 Auto Repair 0 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 O 0 <br /> 0 0 Notice Of Violation Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 1 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`orEXT) <br /> 0 O <br /> 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years i <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <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 /> 0 0 Other: § <br /> Comments <br /> f /n� _./. �I ...m � �6...i?✓%'. - � .. 1 :J�J�/— _/4'.1s' �/Y—.--•—= z7 - �}/ <br /> ,:7,11..../^ //������� F ! •'C f(..` �, 11�... L..�l/i 1-r _'l @1 y i./ i...� - —.C I ®� <br /> i <br /> fY 1.a <br /> Int b <br /> INSTRUCTIONS ON BACK 'Correct:10 Incorrect: X i j P 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 4. <br />