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ns ection Report Number <br /> Waste Tire Sy & Inspection Repor __ p p <br /> State of California N + �'1 <br /> CIWMB 181(New 04/04 Survey Form - Paue 1 ,� 1 0 0 0 <br /> California Integrated Waste Management Board ! J -- -- - -- <br /> Part A- Survey <br /> gY BLUE OR BLACK INK PEN <br /> TPID- {�, ! Inspection Type (Fill one) <br />} Site Suffix: ' / b ' ¢ ,( ll ! ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: y� ' y�, ( �tif ;,} 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name r 1 } _% Inspected By Inspector <br /> Physical Address <br /> 5 <br /> Street I �_ _.. <br /> � L � /� Inspection Date <br /> .�� <br /> City State ZIP Corte Time In _ Time Out <br /> Business Rep Title n-1 : <br /> , �-�� PM � PM <br /> 0 AM � . 0 AM <br /> _ <br /> f � <br /> Operational Status r Business Role Storage Type <br /> (Fill one only) +�I�a (Fill all that apply) (Fill all that apply) <br /> ® Active w t- � Generator 0 Outdoor <br /> ., <br /> MEMO W <br /> ' + <br /> C 0 Closed <br /> Latitude �,,ua > �q i k'�,f. <br /> GPS "� f � �r Vis' " 0 Hauler0,� r. <br /> O 0 Inactive1(�� �trrGjty„tiw� ws <br /> kir # 1 <br /> End Use ” �ai�tatner <br /> Longitude — 0 Planned : �fi d r, <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 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 Other 1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFOf2CEMEN'T STATI7S <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 <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 EX`f) <br /> _ _ I <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 II, 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/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 In Compliance - No Violations <br /> 0 0 Other: <br /> Comments <br /> ` 1 � <br /> D" ` - -� <br /> Inspection Form Included: 0' <br /> Comments Included: 0'- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK CorrectV Incorrect: X J 62081 <br /> i � ,t r I L , <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />