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Ins ection Re <br /> � � �,w Waste Tire Sy & Inspection Repor ort Number <br /> _._ -_ p _ p. <br /> :.Oa State of California �- <br /> CIWMB 181(New 04/04) Survey Form - Page 1 ,� • 1 0 1 3 � � <br /> California Integrated Waste Management Board ----+- - -- - --- -- <br /> Part A Survey BLUE OR BLACK INK PEN <br /> • fi e t "9 2 r NINE <br /> a M�`n„1� ✓ �,: }4h��'YWs'y�'F 5`ai" >'gt ti y'{g, l <br /> '��N'r.,23+r�1; ,^"".7t�, Ihw, h! 00•••J: <br /> TPID- _ r / Inspection Type (Fill one) <br /> Site Suffix: Q Routine 2 Re-inspection Q Referral Q Observation <br /> (; <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> I i'r l ,. t� i �i6' J� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / , Inspected By Inspector <br /> Physical Addresst <br /> 1 { <br /> Street —� <br /> _ Inspection Date <br /> Citv State ZIP Cade Time In Time Out <br /> Business Rep Title O AM AM <br /> {. Q PM O PM <br /> i r^i" 9 {rr i b Su MF .: <br /> Operational Status Tire Tyge I Business Role Storage Type <br /> '" (Fill one only) (Fill ail that apply) (Fill all that apply) (Fill all that apply) <br /> TIr6DClUMNfi`(Wkl �' x, N1111 <br /> (a Active Q passenger Q Generator Q Outdoor <br /> _ --- O 4 Q Closed Q Altered <br /> Latitude I Hauler Indoor <br /> GPS Q Inactive Q Ti uck Q 0 <br /> Longitude – � 0 Q Planned Q C?TR Q End-Use Q container <br /> :i Business Type;(Fill all that amply) <br /> I <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 ® Other � j;,1✓r I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 Manlfesting)kequirements Date ; <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> m m m <br /> Q Q (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <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 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 /> CommentsGCtor i J1, �� i.– i}�'(�rtl E!' Lr`( r <br /> . r , <br /> (Ile ,�r � I i' {� �{`�C� � �` (.. � rr f 'j , l!f rv� v �`7 e <br /> �j <br /> S1„�31tNX, ti_ Orwo QY <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect ^j �/, e I A M P I E I12 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © S <br />