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Waste Tire Su Inspection Report Number <br /> � •.. �y & Inspection Repor , - IoRt r- p - - -- p -- - � <br /> "^ State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 >r <br /> L; <br /> .01 L0 �� 3 6 t 5 <br /> California Integrated Waste Management Board ---- <br /> _art A-,Survey BLUE OR BLACK INK PEN <br /> Business ProfileInspection Details <br /> TPID- I _I �. Inspection Type (Fill one) <br /> Site Suffix: <br /> 1 1, qr` 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 F / <br /> acility Name C Inspected By Inspector �1 <br /> Physical Address <br /> Street <br /> Inspection Date <br /> Citv State ZIP Cade Time In ,_.• Time Out <br /> Business Rep Title ® AMQ EL <br /> AM <br /> O PM1__�� . O PM <br /> militivit all j: lig wit: 1 iiiiii; A Operational Status Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) <br /> ILE 111111111=11EN111i Active 0 Generator 0 Outdoor <br /> GPS Latitude --� — O 0 Closed ' <br /> Hauler (� Indoor <br /> 0 <br /> Inactive g+u u t <br /> Longitude — 0 Planned ��GTw ���f End Use co <br /> �tyt�°ttytl" <br /> ,pp" ,.y,.�� ✓ i e',i:, - v e i �` r✓/i '""7x '.d +k/"i X b 1 W Y [ ,N� i�R ��a""d i 9�� n R a b Fpn,i i i�I 1,��'rb,u� �„ f �f✓�'. u•wr <br /> .I7Q���.��;) �' ' _ .X, ✓ ✓.j Ji :fir a✓ !t�,l/r:-fl x lv°' k'�MF'4:. f ' 4F t:'.�r' � �i�w1 R/�7�"t�'���✓✓,� Y. ✓ +/ ✓f�bl �1✓r ✓✓ H4 �i,;<°fi <br /> .�'��., ,. ,. ✓..-er ��wnu,4�.....::.5.w „�._._,.,w. .�4.,� ��,uy:..����.,.�.�'l a!:... ....✓. �.`�r A �J...✓ .�f ro •, _ r✓. ..n..ne �,M1 a i..✓s }»,,w+°'�.u'l.,,.. ..✓s'� &r r,..xn�”»��ai""�"��.c..[.a.^� <br /> 0 New Tire Dealer 0 Auto Repair ® 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 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 m / m m <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 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 /> j 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: 0' <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X jl�, � :;i A Iiii'li i-' I_i L <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />