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Waste Tire S Oy & Inspection Reportolnspection Report Number <br /> }�1� - / - <br /> � .� CWeM f 181(New <br /> Survey Form - Page 1 ° V 3 f $ <br /> CIWMB 181(New 04/04) � <br /> California Integrated Waste Management Board -... -.._ -3 -__. -.._-. <br /> Part A- Surve BLUE,OR BLACK INK PEN <br /> .• ,"tl� "�et���ra � '� ra Yr ra iso✓1 Y "�jr a& N� °rr� M� t'�Y (�'� <br /> a trnvva _ M <br />� TPID - [Aj] Inspection Type (Fill one) <br /> Site Suffix: 2 n :> ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 7 �'{ If Referral,choose referral type(Fill one) <br /> Identifier: '941 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name T <br /> C" Inspected By Inspector <br /> ( Physical Add ess ._j(� <br /> Street <br /> n �`. 2� • Inspection Date <br /> City State ZIP Code Time In Time Out _ <br /> Business Rep Title AM0 AM <br /> aO PM O PM <br /> --7 <br /> 1 <br /> Operational Status ,tr Business Role Storage Type <br /> (Fill one only) (Fi(I N t 1+ (Fill all that apply) (Fill all that apply) <br /> � , <br /> T,re Coo_ (,. hole!PTE) C '. �r <br /> ' aggi; j Active P E et1 fa/i ce_ Generator 0 Outdoor <br /> T�7 <br /> O " <br /> err <br /> GPS Latitude —� 0 Closed 0 Ali l Hauler Q indoor <br /> Inactive 0 <br /> 0 <br /> Longitude — r O 0 Planned 0 OTR k 0 End-Use 0 Container <br /> tesiness Type (Fill all thda ply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 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 HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation 0 Extension ' <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 or EXT) <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/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 /> 0 0 Other: § <br /> Comments I ` <br /> ��._I� i I✓ , :�- / l i, ); i :�l�i: L'J: <br /> r7 <br /> cab v;_ Lk <br /> l_(( J47fd <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> s 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �/ J :, ,0, _' I_ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />