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section Report Number <br /> Waste Tire Su.rr / &i. Inspection Report _p - --_ p <br /> California e StateBof California Survey Form - Page 14f 5 - 1 01 3 5 4 1 <br /> �� CIWMB 181(New 04/04) <br /> Integrated Waste Management Board -- ----- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Inspection Details <br /> i Tplp_ Inspection Type (Fill one) <br /> Site Suffix: I 0 Routine ( Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �,7 ^ L ! 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 <br /> Street <br /> 9 Inspection Date <br /> City" State ZIP Code Time In� Time Out <br /> Business Rep Title 0 AM O AM <br /> � -E <br /> 0PM � � 0P <br /> Operational StatusTire Type { Business Role Storage Type <br /> any, , <br /> (Fill one only) (Fill all that apply);( (Fill all that apply) (Fill all that apply) <br /> � � �� a Active 0 Passengers ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> Latitude �� <br /> GPS 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> t ,I . .� . <br /> Business Type ' <br /> (Fill all that apply) <br /> Ili 0 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 I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A 1 HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> O 0 <br /> 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 0 114 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 (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 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 in Compliance - No Violations <br /> 0 1 0 Other: § _. ._...... . . <br /> Comments <br /> Inspection Foran Included: 01 <br /> , <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 1�, N/ A 0,'�P ^� �f L .1 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA' ® ■ <br />