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Waste Tire Su y & Inspection Reportomspection Report Number ■ <br /> State California Survey Form - Page 1 - <br /> .A <br /> CIWMBB 181(New 04/04) <br /> California Integrated Waste Management Board - __- <br /> Part A SurveBLUE OR BLACK INK PEN <br /> 151e5t � .":+ <br /> Inspection Type ype (Fill one) <br />} Site Suffix: Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local - f If Referral,choose referral type(Fill one) <br /> 'irie►' ier: } �_ r - - t;, { 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name — <br /> Inspected By Inspector <br /> Physical Address <br /> I TT <br /> Street <br /> Inspection Date -71 <br /> LOU-- <br /> / �` / `f <br /> ('rfy r�� State MZIP Co'de Time In� i <br /> , Time Out <br /> Business Rep Title O0 Am 0 AM <br /> PM O PM <br /> rational Status Buiness Rolepe <br /> (Fill one only) (Fill all that apply) <br /> Wl <br /> �1sfr� .� <br /> Active �)q � f r"� i Q Generator <br /> O <br /> GPS Latitude 0 Closed " �Mxt s�,r "§ 0k, r <br /> ��r h da..pa �,r M°%"1 " @ Hauler <br /> 0 Inactive <br /> Longitude — �� End Use <br /> ® xi'sw <br /> g 0 Planned <br /> _e�.. Z , Vii' h� rrr r� fid�A.r✓ rr�'vv �y t93«'��';n1r�!..,,t rrr£,�rrr.,✓^� it "34 ;��;��„ 'Y"2,m f. sr;�,,.:., Y.nq rr%"i �`. a "t r <br /> 4 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 Registraf 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 <br /> (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> g_s 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I 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 0 In Compliance - No Violations <br /> 0 0 Other: <br /> Comments <br /> Inspection Form Included� <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: L, sir ,fi', I_ 1 1 1 i L.i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� ■ <br />