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Report ort Number. <br /> _w Waste Tire ley & Inspection Rep . p <br /> State of California ... -� .. <br /> i R <br /> CIWMB 181(New 04104) _ Survey Form - Page 1 , t 8710 _Z 1 <br /> California Integrated Waste Management Board --- <br /> Part A Survey yy BLUE OR BLACK INK PEN <br /> TPID- J , - Inspection Type (Fill one) <br /> Site Suffix: ` ? U .® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� .� uct c+ W 1 vt��� I O CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name — Inspected By Inspector <br /> Physical Address (; t [^ C <' .� G' r <br /> Street {. Inspection Date <br /> I — <br /> City Z/f'Code Time In Time Out 0 AM <br /> State L-TBusiness Rep Title ; 0 AM <br /> O PM O PM <br /> - <br /> Operational Status t Business Role +ryH <br /> - :uurnxa^ p b u r ?7*� r a� a�� Kra ar <br /> ( y) (FIII all that apply) lliafl'� al � <br /> "P, <br /> FIII One only) <br /> { @ Active r "° D Generator <br /> O 0 Closed <br /> GPS Latitude 0 Hauler <br /> vMY �"�'u�rya*nuta9,u,y qi <br /> 0 Inactive Drfadl '' <br /> O End-Use <br /> Longitude 0 Planned ( <br /> 3usirke s T re Fri!' I,I i,`f j <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 0 Other I-. <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 /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 14 CCR 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> OO § p m m FTI <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 <br /> (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 /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I a doi tfo <br /> Other: § <br /> Comments 4� L l^ ✓ ♦ C_,C` a� 1 ! <br /> / <br /> �! <br /> % /''' �• � ' Y t f <br /> 10,4 l„ (./y� C.�efrtl�ll <br /> — ,r � �: � '� :�C��_� 1,,,,•,,,; � ��j< � d"c��.,ire � / <br /> sr' + W�✓y>w�r a f� x�p �au " •,�' "� .w�r��u n.tC r4�,�."�" �ti*�'rc �,` • ��p� r k� �u�.j 6 r rr 'a <br /> a w u14� �°�a"n�'"i✓" � , � u++ � a�k G .iw�� )t/.::u„ ',,�.^w"�,r'il'� ( � :"r" '� r �'x t ,� i r�"wr 'Vi u" ,� ��, r, <br /> __ .. <br /> ,� Inc, a 62081 <br /> INSTRUCTIONS ON BACK Correct.� orrect. VI j� g L� f q <br /> ® - <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />