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r i Waste Tire Sur. y & Inspection Report inspection Report Number <br /> 7x State of California K <br /> +` CIWMB 181(New 04/04) <br /> Survey Form - Page 1 �. I 1- - 10 `0 63 <br /> California Integrated Waste Management Board 1. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- //� / Inspection Type (Fill one) <br /> Site Suffix: 7j © 4'1 - ( ,Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill <br /> , �L�r s• _ �7.. o.'e <br /> Q CHP Q CIWMB Q Complaint <br /> 'Q,EdIdentifier: ucational Visit Q Other <br /> Business or Facility Name - -- - -� <br /> • Inspected By Inspector <br /> Physical Address 1 U <br /> Street <br /> Inspection Date <br /> City .State ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> EE I0PM [1] QPM <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 /> El, E:�a MActive C) Passenger ® Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m • (6 Hauler Indoor <br /> Q Inactive 0 Truck <br /> Longitude - Q PlannedOTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q 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 ENFORCEMENT STATUS <br /> VA 'HAULING AND MANIFEST REQUIREMENTS <br /> Q Q :PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q ;PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 •-Responsible Entities Complying with Manifesting Requirements Date Q 0 I S <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <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 Q to Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> y f I ? 41 <br /> 2? I � r G c y ( rtG S Tr- <br /> ! T,G��r w / "c.? '� T' {l-✓ I mac? ft _T T i � <br /> f <br /> rJ <br /> nspection Form Included: Q <br /> Comments Included: Business Rep's Si natur <br /> p' g e Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: } . MP 62081 <br /> .L 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA t ® ■ <br />