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Waste Tire Su4ey & Inspection Re or Inspection Report Number <br /> stay: p t�_ _ <br /> C¢Z�7 State of California � <br /> CIWMB181(New04104) SurveyForm - Page 1 I / ' 1. <br /> California Integrated Waste Management Board { L { y <br /> Part A- Surve BLUE OR BLACK✓ INK PEN <br /> II�Ih(f �31z" s" J[ abr7EO ? ,,,lit .._ 1Y <br /> TPID- f ( , - Inspection Type (Fill one) <br /> Site Suffix: I r `I � <br /> ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J; !- , : :: <br /> _ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - - <br /> Inspected By Inspector <br /> Physical Address M3 ) L I <br /> t.' <br /> Street <br /> Inspection Date M, - <br /> Citv <br /> State ZIP Code I Time In Time Out _ <br /> Business Rep Title n <br /> L� AM <br /> PM <br /> Operational Statustf� ,�� Business Role <br /> (Fill one only) (Fill all that apply) ` <br /> µA' 0Active 0 Generator <br /> GPS Latitude O (& Closed <br /> Hauler + <br /> w� <br /> 0 0Inactive 1�d"+fit lit <br /> Longitude n " End Use <br /> - 0 Planned <br /> oi . 7041 <br /> 0 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> ' V <br /> 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation <br /> V 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date[T] m 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 0 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 /> 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> � µ ti<,,.Wu., <br /> ---—— <br /> Comments <br /> J f <br /> `4,a .d m�„vJl4 �f �I" 'M✓�Mk; IyR WA 4 j 1 AI"" 1 �Iti p,�, ":k^/ ,,�., M1r,i?�; r^;M"}d^ „,"" ,h 'au f2 k tw,.H' x u)� d.:r a m <br /> F IV ,"t�„tT� k''4. n.:.r ��AiAp, y'� .,AMA ,'N�'b...:i! A, ....rb any wa �^ �::, � ^Ft., +P M, �q .�F 4r". ✓.*'.,, <br /> INSTRUCTIONS ON BACK Correct:* 'Incorrect A M P � �� _ _� -� �� 62081 <br /> White Copy:CIWMB Yellow Copy:Operator _ Pink Copy:LEA ■ <br />