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I <br /> � Waste Tire Su <br /> Ay & Inspection Reporto Inspection Report Number <br /> State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 1 3 10 13 4 L <br /> California Integrated Waste Management Board ----.--- --- - - -- <br /> Part A Survey BLUE OR BLACK INK PEN <br /> q .:-,lq ��,Y✓ 1.(r a Y a{e / ti� 'F`s qy q, k fFrvFq',4�'! � '4,✓rv?rd4 r,. <br /> A3 <br /> Bw�sdt�eSs•f+rI yr yY f �rd � `fC� $�a � J <br /> ...,.. �� �s".:gd,�-__ � g+ � '�."�;1+,�n.qfw";qr�:� `^' "�'-�"�,�'e, ns+'rC w�✓' �,."Ml� �__r.. -. u_.�. "- -- -- .�._w. ._...�,..,.r. . �u✓ „i 3 <br /> TPID- Inspection Inspection Type (Fill one) <br /> I Site Suffix: 1 �( I I (zo Routine Q Re-inspection Q Referral Q Observation <br /> Local i t If Referral,choose referral type(Fill one) <br /> Identifier: 1 1. ry ¢ <br /> Vit• �+ t 61.( fj Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical"Address — j Toll o'✓,'( (_ u_J <br /> J�.i't <br /> �_ <br /> Street <br /> Inspection Date � 2, <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title t 0 AM 0 AM <br /> ('PM m ' � 0 P <br /> "Operational Status ;„w�� r Business <br /> R <br /> ole <br /> 77FL (Fill one only) (Fill all that app <br /> l <br /> y) <br /> Q Active Q Generator <br /> Q Closed <br /> GPS Latitude Q Hauler <br /> Q Inactive <br /> Longitude Q Planned QEnd-Use <br /> I <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 (a Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V AHAULING AND MANIFEST REQUIREMENTS <br /> 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 / m / m <br /> 010 114 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 O - -- <br /> 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 Q In Compliance - No Violations <br /> Q Q Other: <br /> Comments + <br /> n q(I f{ (JY") S-) <br /> J <br /> yid(? <br /> � a t <br /> gd. 4NNr 'a'y <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: M1P' E I I 1­TZ 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />