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■ �11, s <br /> ection Report Number <br /> Waste Tire SuAby & Inspection' Repor p _ p State of CaliforniaCWMB181(New04/04) Survey Form - Page 1 10 <br /> t <br /> California Integrated Waste Management Board -- - --- - <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> (a r r"{ tyr; a d alar u�tia 01 R <br /> a is w f��,„r x ^ r., , t <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: (0 Routine Q Re-inspection Q Referral Q Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Street p <br /> Ins ection Date LYN <br /> ( <br /> City c ' State ZIP Code Time In Time Out <br /> Business Rep Title f AM O AM <br /> � 0PM � ' 0 P <br /> Business Role erational Status O i >> <br /> r ars 7 <br /> (Fill one only) all that apply) Cµ ti dl�thtr �iY <br /> ® Active " Generator <br /> =]o Q Closed h� �"� � �rMnA�k4Yw✓ �" qr!"r,,i '�+r�uf�rr� F <br /> PS Latitude IGHauler <br /> Q <br /> a� a <br /> inactive <br /> End-Use <br /> Longitude � Q Planned rN�r��u✓a��,w« �LIV�n e;mµ(7y�r, <br /> µ <br /> , <br /> Zu <br /> ✓n�"7 r ,,.a ,r r irr,5 rrr Nw: ur ✓r C�"S v t „, ~4; �r ,r , m 1.. <br /> Q New Tire Dealer Q Auto Repair Q 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 71 / m / T <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O <br /> 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 Q In Compliance - No Violations <br /> Q Q Other: § - <br /> Comments <br /> if <br /> r,�:. (( <br /> f <br /> ^ C, �!`A) l i l '' T _ f�/ �; G"� r t i (.��.1 i ''t r� rc .,l ]� i <br /> d ! 1 r",li c,( __.`%F' C `i d ✓r'_J t l Y 1`� � r, ,f i( t <br /> 11� rJ1 :.� -- <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ' »r n i C: .� <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� S <br />