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Ins ection Report Number_ <br /> � Waste Tire Su+ y & Inspection Repori� p-_- _._ _- a � <br /> Californ• State of California <br /> CIWMB 181(New 04/04) <br /> Survey Form - Pagel ( 1_. 6 Q 6 6 Z 0 <br /> California Integrated Waste Management Board <br /> Part A Survey BLUE OR BLACK INK PEN <br /> t ra°u ,9 ,4 u i w �re ^f•� t�„N cs n w^¢ :. r xr <br /> yn�,. -,.,^ �,,, n �7 � �$ <br /> . t .. <br />} TPID- , yj Inspection Type (Fill one) <br /> Site Suffix: \ r til <br /> E ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. <br /> - .-�� �'� � ' '�� `"� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Inspected By Inspector <br /> Business or Facility Name <br /> Physical <br /> sical Address <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title (DAM 0 AM <br /> YPM <br /> I <br /> ;; x ; Operational Status re Business Role <br /> (Fill one only) f , (Fill all that apply) )}SII *) <br /> Ire Count(WhO16/P ) C✓� r x Ja <br /> a Q Active (D Generator <br /> .a,. .. 48Nib"r ar! vr4W + pN ''vim Jtl r ' <br /> Q Closed <br /> GPS Latitude QHaUler <br /> 5 <br /> 9r <br /> Q Inactive f,w tf1+` JJ�' s ( #r a s ! rII <br /> Longitude <br /> I J <br /> Planned )T <br /> Bw�slnesl�T� <br /> 0 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 j A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q 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.m /'m / I7 <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 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 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> I - <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 /> - — k <br /> r on. ."wilomw i > <br /> 81620 <br /> j INSTRUCTIONS ON BACK Correct Incorrecr �"t <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />