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Report Number <br /> Inspection Waste Tire Su <br /> Ins Re <br /> � :. *y & Inspection Report_ p p � <br /> State of California <br /> CIWMB 181(New 04/04) <br /> Survey Form - Page 1 - 1 0 1 3 1 1 6 <br /> California Integrated Waste Management Board - - - - <br /> Part A Survey BLUE OR BLACK INK PEN <br /> i M1tar_. <br /> M �s;Profile Inspection Details <br /> TPID- ) ( Inspection Type (Fill one) <br /> f Site Suffix: j �� r( t11 ✓? / Q Routine Q Re inspection Q Referral 0 Observation <br /> - --- - <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: ', t 11 J t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> � . Inspected By Inspector <br /> Physical Address c--'�— `• �'1 — � t �) <br /> ) ' (t <br /> Street ,. <br /> n <br /> Inspection Date <br /> City Statf ZIP Code Time In Time Out <br /> Business Rep Title AM j / Q AM <br /> vf',V'? -,�- <br /> A i 11 <br /> Fl Operational Status �, i f Business Role <br /> r�°P r n rt <br /> 1 (Fill one only) f (( II l (FIII all that apply) <br /> rt y e <br /> Active )I S J I Q Generator " , 0"N <br /> 0 <br /> Latitude <br /> Closed � p µ <br /> Y <br /> 0 Hauler <br /> 0 Inactive kl G�� a"a 1� ✓ �c i yt�� uu <br /> Q r �ur»lY,bw ;rr�iml tl' r�,,y >✓� % � ,. <br /> Longitude End-Use <br /> Planned <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader o Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A , PR UL4N9 AN\D-MANIFEST IREQUIREMENTS <br /> dTransport of Tires i 0 Notice Of Violation ( Extension <br /> 0 O § g' p <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV`orEXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred f CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 in Compliance,- No Violations <br /> Other: <br /> 0 0 § <br /> , �, ; ,���. .�,' �, F;w"d, <br /> Comments <br /> L/I <br /> 1A-r Leo <br /> aJ <br /> i ( <br /> Inspection Form Included: Q <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Ph_qhe Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> I <br />