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ire Waste Tire Su4ey & .Inspection Repo. 'nspection Repart-Number . <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 1 4 - 1 3 (r � - <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection.Details <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: J G <br /> ® 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 `j <br /> Inspected By / Inspector <br /> AJ <br /> Physical Address _J ) — o / I �L G�!�--(. 'j l Gf .t <br /> z� E a',i ,1 , -- <br /> I <br /> Street j Inspection Date <br /> �/� cy I <br /> llC f 1. <br /> I �- �W.• rI �✓! � 'J`�4`� I <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM1 0 AM <br /> FFIMOPM m 0 P <br /> c�: y� -� ' IBJ c�, � , , ��� ,1� ►� � - — -_ — <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count Whole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> > ❑° <br /> L (G$Active Passenger Generator Outdoor <br /> O 0 Closed �Altered <br /> GPS Latitude m • Q Hauler (D,Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned OTR 0 End-Use Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer (&) Auto Repair Q Trucking Fleet Q,Government Q Retreader Q Dismantler O Dire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder O Other I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> --- - --------- - { <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O ' O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> O 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> ..............--------- <br /> 0 0 <br /> 14 CCR§18459.3-Retention of Manifest.Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for.Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § +��" �� tt <br /> Comments 'TVA S U'G{..�/t . ViC 6, I )v4:JL%t r 0 <br /> �. <br /> St --t�: <br /> 1�I? t'rC � ��r 01, L14 - -)/ f J r_ <br /> I� L!` r' �P I � ! � <br /> C ' L I�'�q r�•t { G `;� 1�I P✓L� °(.l . All v(e llI v'11 !�� �i f I1 G✓p . 6i) <br /> Inspection Form Included: , <br /> Comments Included:0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 0\/ <br /> .� 62081 <br /> INSTRUCTIONS ON BACK �rrect:� Incorrect: ( ) ( 0 E .{� Int P I� rI 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> s <br />