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Waste Tire SuSy & Inspection Repor spection Report Number <br /> ` State of California i <br /> CIWMB 181(New 04/04) <br /> Survey Form - Page 1 3 - 1 0 0 0 0 0 1 <br /> California Integrated Waste Management Board —_ - <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Lns eta N' r>ft �tr � I,a� AJ�xt aL rra& , <br /> TSite SuffiPID- x: - Inspection Type (Fill one) <br /> ` �.� � � �-i <br /> l 1 <br /> _ QRoutine <br /> QRe-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: u yrs CU. b`,.^f <br /> , Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> IT <br /> Physical Address - <br /> l Street <br /> c" � �� 7— r,� � Inspection Date Q (.,, / '� � / E�] <br /> JJ r 41-0"A C-�1 l L <br /> City State' ZIP Code Time In -] : F__FTime Out _ <br /> Business Rep Title O AM Q AM <br /> 0 PM 0 PM <br /> -- <br /> J I � t� � r '1 I fes; W �uF 6 ya r <br /> Operational Status Tire Type t �lgry Business <br /> (Fill one only) (Fill that apg1�5 (Fill all that apply) <br /> Active Q Passenger Q Generator 1Iut u`a't <br /> O Q Closed Altered <br /> GPSLatitude k Q <br /> Q Hauler <br /> Q Inactive Q <br /> 1 <br /> Truck <br /> Longitude — . Q Planned Q OTR Q End-Use Q Container <br /> !!! <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Notice Of Violation @ Extension <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 DateRE <br /> IE [11 <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 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/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ® 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 / 1 <br /> trt`�'l'Clit-ri "_ -' a;. ./ ''tct::l '�:,r Zh�.ir l���"�; c-d ��rl..h�,jz l:,°{�)���' tl4vV <br /> Gv"�61E�_;�,�P . J`rr�' �ir�S AC Ve b�P#t 116ulec �lefi, `tL,rre fore P16 Vlia_hilecl <br /> oya�� a-0e For in�pecttUvt, EXf��o t� ravll , � +0 Vol u5 3f0Ul4 <br /> r F' <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X ��, ( . .;h ,`+; "' p. L 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />