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Waste Tire Suo & Inspection Reportpection <br /> Survey Report Number <br /> State of California <br /> r. � CIWMB 181(New 04/04) ey Form - Page 1 3 - i Q 13 4 0 8 <br /> California Integrated Waste Management Board - — -- - ---- - - -- ---i <br /> Part A Survey yp'' BLUE OR BLACK INK PEN <br /> r ` 'W :r"i r E' �"^"k 00, :a '�` /r.'%t�a{w�1^ rt wf �+l'war A4t� <br /> Bus no <br /> 1,.,,1,21 "_'r�..=..'ate �,�'�jWE�y '.,��'�S?"�,.w.�.�..������^��W� .�f' '�.�:.� �,2�„. <br /> i TPID- Inspection Type (Fill one) <br /> Site Suffix: Q �(. (� 0 , @ Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. 00 r Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name c Inspected By Inspector <br /> Physical Address T s W i �l <br /> — <br /> I <br /> -' 'I C', C <br /> 0" H Vj <br /> Street <br /> ?' - Inspection Date ( <br /> L � � r' <br /> city state Zlf1 ") Time In Time Out <br /> code <br /> Business Rep Title -�j : =, <br /> AM O AM <br /> O PM j t1 PM <br /> CA(')Y)G <br /> �,.. Operational Status ireTypeBusiness Rolea <br /> ", (Fill one only) (Fill that appty)1 (Fill all that apply) <br /> Tire Count(WholelPTE) <br /> / Active Q Passenger ® Generator <br /> D Q Closed Q Altered <br /> GPS Latitude 1tr+i t- Q Hauler Q Indaor <br /> O <br /> Q Inactive 07 ir1 <br /> Longitude — Q Planned Q-OTR Q End-Use Q Container <br /> Business Type (Fill all that apply)°"'" <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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 m <br /> Q Q 14 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 or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators �.In Compliance - No Violations <br /> Q Q Other: § •.,.. , . " , <br /> Comments .. Op IAJ <br /> r <br /> 1 ;. <br /> ,s + -1,, i i ! —f ; ;� t �' ;(." f ) l ! ; r; 111-( (, , ; I . � �,; <br /> �'� <br /> -r 1 l.��J� ' r' <br /> r <br /> Inspecf"ion Form` Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature p Phone Number <br /> /� i T -1 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: � A � �' l_�� � � <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />