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Waste Tire Su* & Inspection Report 11- -spection Report NumberState ■ <br /> CIWMB181Survey Form - Page 1 I - 110 <br /> CIWMB 181(New 04/04) L� <br /> California Integrated Waste Management Board - - ---- _0 <br /> Part <br /> - <br /> Part A- SS BLUE OR BLACK INK PEN <br /> TPID- -� _ Inspection Type (Fill one) <br /> Site Suffix: <br /> FO F3 -? �,� (5 Routine O Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �. ' `-; Q CHP Q CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Ph sic I Address - - f <` L . % ; <br /> Sheet �—� <br /> Inspection Date <br /> r <br /> State Z/P Code Time In Time Out <br /> Business Rep Title Q AM ��� O AM <br /> a PM 0 PM <br /> Ld - <br /> M- Operational Status, Business Role <br /> (Fill one only) (Fill all that apply) (`" <br /> r4 I <br /> NONE:] 0 1; 6a ��tix�dr��G�x �aCw�iti a✓i <br /> Q Active c y f,� ® Generator <br /> � Closed <br /> Latitude 1,So1I�N ) ® Hauler� <br /> OO Inactive 4a r <br /> i <br /> IEnd-Use <br /> LonItUde Planned <br /> I <br /> 14 <br /> i <br /> °_ ._.sir,-�4 <br /> Q New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder O Other �—— — <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS J <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ® Notice Of Violation Q Extension <br /> (a Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers, I Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date7.- / EE <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB III <br /> 0 O 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 c�..- <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ® O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: § --------- ---------_ ----- ----- — <br /> Comments <br /> /Y', <br /> psi% r <br /> INSTRUCTIONS ON BACK Correct:* Incorrect. ( cl' yi ' � 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />