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Waste Tire Sufty & Inspection Repornspection Report Number <br /> State of California <br /> C181 e ) <br /> California Integrated Waste Management Board Survey Form - Page 1 - 0__-._0 6 5.- . 0 <br /> _-.....-.' ■ <br /> Part A- Surve _ BLUE OR BLACK INK PEN <br /> Chi» aa1iS�G <br /> 5?� � ..u,-WAN <br /> ISSite <br /> - Inspection Type (Fill one) <br /> Suffix: ���� + �-�1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local — If Referral,choose referral type(Fill one) <br /> Identifier 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> I (.-_ -- <br /> Physical Address <br /> Street <br /> j � ^ Inspection Date - <br /> I <br /> City State ZIP Code I ime_in Time Out <br /> Business Rep Title l 0 AM 0 AM <br /> F I 0 PM m _I 0 PM <br /> Operational Status Business Role �S ' <br /> }kp rd. �w hkA miw Wks. <br /> (Fill one only) - )� �pl`y; (Fill all S that apply) <br /> 0 ( Active ' � ger i Generator <br /> a r�ak <br /> GPS <br /> r �� f4 ,t� <br /> �+ Latitude EE 0 0 <br /> Closed ' `";"� 0HBUIer ���- 7 a�'d^"";+����`h"✓✓��'. <br /> inactive µ <br /> Longitude — 0 End Use l <br /> 9 0 Planned �,� r. <br /> itk4, Al <br /> ype ,(Full s,. ... v <br /> 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 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <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 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/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 /> 00 Other: §`--- ----_ .__ <br /> CommentsJr <br /> y l <br /> -- <br /> t � :r <br /> i' <br /> 4,5" fir `;.� l.arr 1 a r� <br /> INSTRUCTIONS ON BACK Cor ect. In,dorrect � "r p s2os1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />