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Waste Tire SUW <br /> & Inspection Reporspection Report Number <br /> ■ ,�.,-°. StWMB 181 California <br /> lif or w 04/04) ( ' -- .a --- ; <br /> Survey Form Page 1 3 t 10 3 <br /> California Integrated Waste Management Board - - <br /> Part A Survev BLUE OR BLACK INK PEN <br /> 14 '4�', <br />} TPID- ��j LL� � / Inspection Type (Fill one) <br /> Site Suffix: � y �3 `T tJ + �,,Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> _. <br /> Physical Address — TT I , ,.f - <br /> r Inspection DateMILD <br /> City % State J ZIP Code Time l_n_.....__ Time Out <br /> Business Rep Title 0 AM <br /> � : W O PM [= , O PM <br /> - <br /> -F—- L <br /> r Operational Status Business Business Role q ` i{ <br /> (Fill one only) a�11(e�(111a15 (Fill all that apply) ' <br /> ^ A"ag ""�+ M r. u•t rn 4 rn� <br /> �.. <br /> Active Q Generator jn{ J� r <br /> Closed <br /> �+ Latitude Q qtr' nyw ✓ i r'r « Hauler A`"'' '""�,��bror" an>n 1 <br /> GPS x /f� r rn� Q ;��, " <br /> ���_LLL����JJJ Q Inactive "r .�`� A r y�; if4 n n <br /> [] ;"r ;r a�J)fh wr d"v <br /> Longitude Q Planned wa�nitn� Q End-Uses" tSn�If�er <br /> �.t <br /> B ineSST�/pe',(0fll�t <br /> &,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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m / M / m <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 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 In Compliance - No'Violations <br /> Q Q Other: § <br /> Comments <br /> or,. �?.q �r a r�t„ , a ;is � ., rk r a r a r✓• na f r x n q y kt' i r M+�,d rh a, f+ rpt yqyr y ;r� r:..., <br /> < <br /> 4;1 <br /> ~ <br /> i <br /> 62081 <br /> INSTRUCTIONS ON SACK Correct:• Incorrect: X I� F 1AMIP E ' I � <br /> L it <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />