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Waste Tire Su & Inspection Report _ .-Spection Report Number, <br /> fag State of California +t 7 <br /> CIWMB181(New04104) Survey Form - Page 1 1 t 4 10 <br /> t t 4 <br /> California Integrated Waste Management Board --- - ------------ - - - <br /> Part A- SurvieBLUE OR BLACK INK PEN <br /> „rY . S ..t_a,~FfallaftLBusine$su� etW ,f ) �p F d u'/ [,. �y ax C <br /> ..� <br /> TPID- �' Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection Q Referral Q Observation <br /> Local ( 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 Inspected By Inspector <br /> i <br /> Physical Address <br /> Street Inspection Date <br /> / <br /> C' <br /> ,rtt <br /> e —_ �� <br /> e ZIP Code TimeIn Time Out <br /> Business Rep Title �l Q AM 0 AM <br /> 1 D <br /> �I . 0 P [:T0A <br /> ' PM <br /> Operational Status F ,; Business Role <br /> P did <br /> (Fill one only) (Fill all that apply) � x <br /> rad Active ® Generator <br /> O <br /> Latitude Q Closed <br /> GPS t � r ' Q Haulers �r � t1w17 <br /> R*r <br /> ti� <br /> n!Qinactive <br /> "�o <br /> Longitude nd Use <br /> n <br /> P <br /> � <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber (ic Y t r > f/O y l t <br /> Q Service Station Q Hauler O Agriculture Q Shredder (a Other I F?- fl�r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility � FORCEMENT STATUS <br /> V A' HAULING AND MANIFEST REQUIREMENTS <br /> O O Q Notice Of Violation Q Extension <br /> MPRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 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 /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 11 ,Com nitan a No Violations <br /> O O Other: § 1 ds,Gc k,� ip 4d <br /> Comments !. r ( Z l )( <br /> / <br /> L{ j L 0'e, !{✓Uj t A (/�i c -�Q C<< t rl'1 C�(� r� lJ rLl r. f e SC r V l C': Gr r, <br /> T k y <br /> )o(.-J Il k v�G �r, `�vt7 j C/ I re .. 04 V p ild")�' <, t�C. o �.1?1 �Y�r'��^", 4 �1��r1� ✓i t' <br /> o vo rn rtj <br /> i <br /> I <br /> I <br /> INSTRUCTIONS ON BACK 1 Correct:0 Incorrect: <br /> White Copy:CIWMB Yei"� ,' �. s2os1" <br /> ■ - <br /> Yellow Copy:Operator Pink Copy:LEA 'i <br />