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Waste Tire Sui . _:y & Inspection Report Inspection Report Number <br /> II. State of California j <br /> �7'7ai <br /> CIWMB 181(New 04/04) Survey Form - Page 1 V y��1 V h <br /> L <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 Inspection Type (Fill one) <br /> Site Suffix: ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: c <br /> Cts i V r� 0 CHP 0 CIWti1B 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> L�� Cid <br /> Inspection Date •I, Q 'Z zk S <br /> Time In Time Out <br /> Business Rep Title O AM _ O AM <br /> VV" l� t \ * PM J l i®PM <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 /> ® Active 0 Passenger (A Generator ®Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 ® 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 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <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 /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 # 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators #r In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments (-] 1 ��` �� �� �� ""' 1 � �• <br /> \V\ rr t 1� 7 �-�1,3�c- S i a�. vl �� L(�oY�5 VV b� <br /> Inspection Form Included-. 0 <br /> Comments Included: 0 � � ? _G' 33-Kra` <br /> uB s�'Signa re Phone Number AInsector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X .ik \/ X ft Nt P (_ 1 i 62081 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />