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Waste Tire Suy & Inspection ReporInspection Report Number ■ <br /> ■ _ <br /> "11••is'S State of California ,1 0 <br /> CIWMB181(New04/04) Survey Form - Page 1 1 6 - 1 0 13 4 <br /> - Y g <br /> California Integrated Waste Management Board --- -- -- <br /> Part A- SurveyV <br /> esBLUE OR BLACK INK PEN <br /> P MSG b`�tl( r� <br /> Busins:Praftle;' 'Ins ectia <br /> TPID- Inspection Type (Fill one) <br /> f Site Suffix: �( C� ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local -- If Referral,choose referral type(Fill one) <br /> Identifier: J({ J OOt ��,tyt i � L_�` 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name! Inspected B Inspector <br /> P Y p <br /> Gv, ol 4a cv' l �� t�✓ VICfj. – EED <br /> Physical Address — J( y e t L K `� I v _�) <br /> VJ r <br /> Street <br /> YI r 1 Inspection Date <br /> City — T I State ZIP Code I Time In Time Out <br /> �._. <br /> 11 AM 0 Am <br /> Business Rep Title , ) : [T <br /> 1z" <br /> 0 PM ( ! t O PM <br /> El1I <br /> �—.- <br /> . P. <br /> I � Operational <br /> Status Tire Type <br /> BuType <br /> I <br /> one only) (Fill apply)! ll all that apply) (Fill all that apply) <br /> Tire Count WhoI PTE <br /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> (�� � O 0 Closed 0 Altered <br /> GPS Latitude W , _ Hauler 0Indoor <br /> 0 Inactive 0 Truck <br /> Longitude – 177-1 . F-F-F-T-[ 0 Planned 0 OTR <br /> 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 /> 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 0 0 <br /> Notice Of Violation 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 M / M / m <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 0 In Compliance - No Violations <br /> 0 0 Other: – <br /> Comments <br /> �L. VIJl,.<Jc(I j(f <br /> tt - <br /> Ins ection Form Included: <br /> p O <br /> Comments Included: O <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X /P A�I'w'.l I_. <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />