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M Waste Tire Surma & Inspection Report spection Report Number <br />• State of California <br /> Survey Form Page 1 10 3 12 9 <br /> CIWMB 181(New 04/04) <br /> o <br /> California Integrated Waste Management Board - - --- - - - - <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> ltlspection Details <br /> TPID- inspection Inspection Type (Fill one) <br /> Site Suffix: — � 31 31 1--4 Cj Z ( s ( ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: COY p� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address [r %] r .C_ (1,7 �) <br /> Street <br /> Inspection Date Q + / E�, R In <br /> 171 <br /> �- <br /> I /_z:>d A �� <br /> Time In Time Out <br /> City State ZIP Code _._._ <br /> Business Rep Title 0 AM 0 AM <br /> O PM O PM <br /> 1 <br /> LA 4- f',y1 - <br /> Operational StatuBusiness Role Storage Type <br /> — --- yr. s � s),� r�r �4� ,. <br /> 4i (Fill one only) � 31rt �31y), (Fill all that apply) (Fill all that apply) <br /> i ® Active a ,Cr Shc (6) Generator 0 Outdoor <br /> -- — p 0 Closed <br /> Latitude <br /> GPS yrs a �rr,k) Ir 0 Hauler 0 Indoor <br /> _LLL 0 Inactive 'a�rTkd ' a«fi rn r; <br /> �rrri <br /> Longitude Planned I 0 End Use 0 Container <br /> Business Type (Fill all that apply) <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 /> rr. I <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder �'� Otherf— <br /> _ -,-- —f— <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> U A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 0 Notice Of Violation 0 Extension <br /> 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 M / FTI / FT] <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 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 /> 0 0 Other: § i ;, o, <br /> Comments � ,^- � ,;' ,.•" <br /> Inspection Form Included: 0; <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> / "�— 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X �, V ,} , ?rrr I 2 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br />