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• <br /> Waste The 81: 011$ eCtlOn Re' Inspection Report Number <br /> p� _ _ , <br /> � State of California � � _.... - ■ <br /> Ei33�9 CIWMB 181(New 04/04) Survey Form - Page 1 � � � � � � � � .� j � <br /> California Inte rated Waste Mana ement Board - <br /> Part A�Survey s BLUE OR BLACK INK PEN <br /> r )sr r rr;n ry"F ^r v'ry � � "rµrd+a ,.«s�1� ar rar S ',a v. � *[r� +a'M r, r„"4'i i',.'„z v c ,�vi;�+ f� �v:,v r- r,..;.. <br /> ��.�a'� a a v,,r.�..'�� >c ,�,m;�*:':='a �k.'hr,^ nG ” v ,1� M. w ;'l �. 7v ;, � <br /> �:_.v.r. ��....._.,_r F.� �' r ry „';;" a M, ,:�.,., a,"'~a,?4�t� „�„.�, a� x ,,.�;� � � ,� ��. I, lr� b:m✓»,�,'yar”ia:,,a`,a .,�a'r7FF."F�d,�,i r v �;��"x mr�M ,,r r^�5 ni�nrr�M�fwtia. �A v y.�r i�: <br /> .��...�.�.>� "�.,:�M.�.� vi7..�, 5.� � d:. ��� �.ax. �v<r�r�� 7..�z:`rP,�6±'vlvry'�;kr+wrN�..,9,f n,�'v i�,�itA'"n�r��t�, l�,rCV��p�'�"`�."�.y, ^,�r�'�'�"��rtf_3v„i��li��ar��✓���_"Gam! <br /> TPID- c � ,,, � (,, � Inspection Type (Fill one) � <br /> Site Suffix: �l I r: � � r � i — � � Routine Re-ins ection <br /> Q Q p Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> i _.__ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name � - - - <br /> _� <br /> Inspected By Inspector <br /> � t,,,y.r t `,j< <�, ., �` s` <br /> �. � I / ��� <br /> Physical Address 1 �� - � �, / - uti r <br /> /<-�� ;F�/v /� <br /> ; � r f <br /> Street <br /> 1 _��� i� Cl Inspection Date /,? "� / �> � / � <br /> Cify � State ZIP Code (Tim_e_In Time Out <br /> Business Rep Title h �� • I �O PM �_"�_1_ -_..I • C_�� O AM <br /> _ �J O PM <br /> I -- — 1t P � m ��" Ar7�ry,r'"r s�,� � i �'a'fv l `"v9v <br /> � Operational Status i�°�n � r� r ryn r Business Role <br /> (Fill one only) � ����� ��� �(Fill all that apply) ��4 � I, . <br /> 0,:'i"�� Q Active I(,� �a'��i� ,+ �� � Q Generator �a-�a ������ �" <br /> C_�� a �+n a t n , � <br /> � c pt'1 L�^- <br /> Latitude - Q Closed )� � � � �✓��i r����� 1� <br /> GPS ��� �`�� �q ,��, �`� `���,��� <br /> _ _ Q ¢�t4 ��r �r � u +r� Q Hauler i)x� � �. <br /> �i0 Inactive "'�� r� +�f*" � r t � r <br /> Longitude - '�'����„����� "i�` �^��; � Mt ��� d���� ro+ <br /> • � Q Planned ���, ���+� Q End Use ,� 4 <br /> nw�"'!r-`��' � s �:+unrn __ ..,_ .� v �,ryu ' 'v'�^f �� .. i^,r^pm�,a"i �, �”r��� <br /> yy�U `t,... ,,' , �,. �,r � <br /> 1.;:17 k � .. 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JM v r,„ rr,'^ r, rd ,,:, s r ,,. e �^j�'� �r,X �„ „ � , <br /> [.,. r.. d v. ,�.:u 1 a� .,..."., a :+.,.... 1Ra ;v ...a. ry z ., y ,o.. �+ <,..,. y ��,, <br /> ..� r_.,....-..,,.� �. ,,...a..,.��r_h. ,..,� ,v ,1 ✓,n P, � 4 ,ir, h.„%” �t,,,� „✓,..., x n, ,.YJ ,^ ,.Y rr .„;. �"MF r.:.an't ,�1.+4.:nr r r 1 "� , ..i'.'��a t� ..v�Y a` 31�,.t a l � Jr <br /> �,...—�.W✓� ...�.�._k.��..x...,�,_.t.�,..s..d..,ur., ,�.�_.�,,. r��wr✓„::"m "?��w ^t>v:..za�L�:at"1�c,�.Laxl ar z?.,Cd,�.,r.:,,ra"��.�c.�/,„,.9u,r�r°.���'��`S,yu;�rv�ur"�..�.��ryk4„�i�s";.t"".�`: tvyrd. nL"`u � vr,rF r ^arr <br /> Q New Tire Dealer Q Auto Repair ;�� 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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility E_N__F_ORCEMENT STATUS I, <br /> - ” - -" -- <br /> N � A �HAULING AND MANIFEST REQUIREMENTS <br /> Q Q �PRC§42951 -Waste Tire Hauler Registration and Transport of Tires I <br /> Q Notice Of Violation Q Extension <br /> PRC§42953-Contracts with Re istered Waste Tire Haulers. <br /> Q Q 9 <br /> Compliance Deadline. ` <br /> Q Q PRC§42956-Registration/Decal in Vehicle I <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements I]ate i <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m � m / m � <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)` I <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 <br /> Q Q Other: § Q In Compliance - Na Violations <br /> Comments r _ <br /> r � r'� _.— .- �— <br /> // / <br /> i _ r_I'/ �L��- i i/�(7� C��L/� /��.r i 111 <br /> Ins � �.� C � � �„� "�r ��" Wf/�,�}� a ' "y� a”� y, � ,. d 1 V !° a r , <br /> � �,'ar.�a;+., d �u��v*t+ r 4 ��r.��r,"N a! 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"� .;ry x,a ^^.'�'� fir.� �.�r G" c^ µ, t'� �w <br /> w?e '�y� n , a k�ixt16,5`I�t@Sy� �� rf' ✓ ^ �r ��war�� F 7a t a� l r�rr,�,~��ur� ." a <br /> � ��W��; r � ������"a.Lc��e„r �.� ��-„ ."n +l�M,�,^,,,�v '.>��L u„ � .rvn�°-��.�."`�.,�"�r 'a ,.w��� ���✓�`%i�v� �i��„ <br /> ._ a� r ..y�,r. .� , . .�n. h.„'n a � 3 a' w l r <br /> INSTRUCTIONS ON BACK 'Correct: Incorrect: I i , � II �` 'i�( �,�”; �' I_�C � 1 t �� 62081 � <_� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® t <br />