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® Waste Tire Su*y & Inspection Reporfinspection Report Number <br /> ■ <br /> PartA- SuStateCalifornia Survey Form - Page 1 1 0 2 5 6 1 1 <br /> CIWMB 181(New 04104) f <br /> Cal,fornia nia Integrateded Waste Management Board <br /> rvey BLUE OR BLACK INK PEN <br /> �.,.,..v. <br /> a.` '� ,nYv+i,: 'ze ��� a � r �.'r3, <br /> S�r1eS8 profl( n It <br /> v_S,�.listev _,"G <br /> �5wc���,. - ��� r, + ,�1.�.>✓.ti.*w.,.^�»'i _�'s'r;~�.}�!�ti+.at'' W.U, i't'^ <br /> TPID- - Inspection Type (Fill one) <br /> Site Suffix: I 3 � �l <br /> Q Routine (9 Re-inspection Q Referral Q Observation <br /> Local �''�" If Referral,choose referral type(Fill one) <br /> Identifier: ; t � r Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> rr r. Inspected By Inspector <br /> 1 � <br /> Physical Address <br /> `� �, <br /> I �" �� ! —� ;��Irp ot t <br /> Street �]— <br /> Inspection Date <br /> City State Zlp Cade Time <br /> TimeIn I^gFtrin�+iay p�q�q a a✓�nr,�f#q�fit�g�r aY�A� �f�f:rrrihaa^ryl�zy;Time Out <br /> 0 AM FT—] <br /> "rlrky�a ry#g�J��It tl f�nrneYt n'fi <br /> Q <br /> nt#or�n <br /> n lfw <br /> 0 PM 0 PM <br /> -1 L_ <br /> Ar <br /> MBusiness Rep TitleEl- <br /> 0 A Operational Status rBusiness Role <br /> (Fill one only) (Fill all that apply) <br /> o- ® Active � Generator <br /> oCLatitudeHauler <br /> Closed �x <br /> 1 <br /> ti <br /> Q Inactive <br /> Q na�� t 9t �4"tatr lett )n 4n <br /> Ott tti �t "iJ 'i � ��r <br /> Longitude _ )ter ,+� �rr <br /> Planned yn nna✓. LJ'End Usee+r <br /> N <br /> Q `Y� a, YC Sv, rn �'nn } 7 t nl <br /> , l�wr rrp.,N.ia,rrr 9✓'tr r 'r,unumr4igr�«-:, P,��' �" n„,�..M N^"�Y, � u.�� i....r�w'n" np;.,H.;r "'Ynw.yrw"7+..va°b✓^�ru�>'�lo✓rrb"�rn",,. <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 L. , <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 Date <br /> z <br /> Q 0114 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 orEXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> -- -- -- - — --- <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 I Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q I Q Other: § ; <br /> Comments <br /> Inspection Form Included`. Q <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ - <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: X 62081 <br /> 1. ;�;, , ��, - e 1 c. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />