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r- <br />■ `4 Waste Tire Suy & Inspection Report Inspection Report Number f <br />1 <br />NEU, <br />Stite of CaliforniaCIWMB 181 (New 04/04) Survey Form - Page 1 ( -.0 ' <br />Cal)forrffa Integrated Waste Management Board <br />Part A -;Survey BLUE OR BLACK INK PEN, <br />Business Profile <br />TPID - <br />Tire Type <br />Site Suffix: <br />I <br />Local <br />(Fill one only) <br />Identifier: <br />(Fill all that apply) <br />Business or Facility Name <br />AV 40y, PCXR <br />Inspection Details <br />Inspection Type (Fill one) <br />(ERoutine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />Street <br />, l'•, „ -/ 5 - J Inspection Date <br />City r State ZIP Code I Time In Time Out <br />Business Rep Title <br />:m0AM m.m 0 A <br />tfilrt� l�DP .6' v,l"rf� --- 0 P — - OPM <br />dc. <br />Tire Count (Whole/PTE) <br />� f <br />GPS Latitude <br />- Longitude _ FTTI - I I I 1= <br />Business Type (Fill all that apply) <br />Q Dismantler Q Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension I <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />Q,In Compliance - No Violations <br />a�J,i e �Ij -l 0 � hl(," or )-e S S Inspection Form Included: 0. <br />Comments Included: 01 <br />Business Rep's Signature Phone Number Inspector's Signi <br />'INSTRUCTIONS ON BACk Correct:* Incorrect: X p <br />■ - White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />n n -0 1 � <br />62081 <br />© ■ <br />n <br />1 ■ <br />Operational Status <br />Tire Type <br />Business Role. <br />Storage Type <br />Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />Part B - Inspection of Waste Tire Dealer; Generator, Hauler and End-Use.Facility <br />(b Active <br />@ Passenger <br />Generator <br />Outdoor <br />O <br />Q Closed <br />Q Altered <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q Hauler <br />@ Indoor <br />O <br />Q Inactive <br />Q Truck <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q <br />Q <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Q Dismantler Q Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension I <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />Q,In Compliance - No Violations <br />a�J,i e �Ij -l 0 � hl(," or )-e S S Inspection Form Included: 0. <br />Comments Included: 01 <br />Business Rep's Signature Phone Number Inspector's Signi <br />'INSTRUCTIONS ON BACk Correct:* Incorrect: X p <br />■ - White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />n n -0 1 � <br />62081 <br />© ■ <br />n <br />1 ■ <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet . Q Government Q Retreader <br />Q <br />Used <br />Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q <br />Service Station Q Hauler Q Agriculture Q Shredder Q Other L <br />Part B - Inspection of Waste Tire Dealer; Generator, Hauler and End-Use.Facility <br />V <br />' A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />. Q <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System. Requirements for Tire Dealers or Waste Tire Generators . <br />Q 1 <br />Q 1 <br />Other: § <br />Comments F •F e <br />Q Dismantler Q Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension I <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />Q,In Compliance - No Violations <br />a�J,i e �Ij -l 0 � hl(," or )-e S S Inspection Form Included: 0. <br />Comments Included: 01 <br />Business Rep's Signature Phone Number Inspector's Signi <br />'INSTRUCTIONS ON BACk Correct:* Incorrect: X p <br />■ - White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />n n -0 1 � <br />62081 <br />© ■ <br />n <br />1 ■ <br />