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Waste Tire SuAy Inspection Report Number <br /> � �y & Inspection Report <br /> r. - - - <br /> �� State I3 California Survey Form - Page 1 3 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board ..._.. _-_.. --.-_. ... .... -I <br /> Part A Surve BLUE OR BLACK INK PEN <br /> �. ,ultrt y�-".�t'�� ,?�,:.-i � � r'"*�^�m�^M✓'1 4r �m"'fi e�,yulf' ��ry� . *�tv� r r*; .r p h; a p r-' "� ✓y- q *.- a :t" rvs.1l <br /> �.,.�? •. �� �. ,, r—J pc,�, F � ��' ,��'r���"4�,�r+✓ �prf��y� �t��.�khf~,1"3 'fir "� ra " V !'�ra�9 �� rr� � y ill <br /> TPID- rr ��,���of �, _ �� Inspection Type (Fill one) <br /> Site suffix: ' �L �(.`�t �` �" ® Routine Q Re inspection Q Referral 0 Observation <br /> Local L / If Referral,choose referral type(Fill one) <br /> Identifier: r.:�i` {; .'d i f ' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> /1 •-- <br /> Business or Facility Name -- - <br /> Inspected By Inspector <br /> Physical Address I E/ <br /> Street <br /> l Inspection Date i <br /> City '- State ZlP Code Time In Time Out <br /> Business Rep Title 0 PM 0 PM <br /> 0 AM 0 AM <br /> LLJ : <br /> r f >'}( ( j,. _—J I_L �✓J r' l�-1 } I .�I <br /> (l Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> LL <br /> C Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude __LLJ 0 Closed (� filteredGPS 0 Hauler (� Indoor <br /> 0 Inactive 0 Truck <br /> Longitude - � 77-7—T177710 <br /> 0 Planned 0 OTR 0 End-Use (] 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 /> 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 /> - 0 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 Ell / LII / IE <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 I 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 <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments i <br /> ;T V, <br /> - <br /> �rr r r <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �,. �i �.._' _ 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />