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:{It n-_s }e-.-c_tio_n_Report Number <br /> Waste Tire u V Inspection Re or _ <br /> StateofCalifornia <br /> CIWB 181(New 04/04) � V � y 7 � <br /> " <br /> California Integrated Waste Management Board survey Form Page 1 _ <br /> - ■ <br /> `Part A- Surve BLUE OR BLACK INK PEN <br /> �1 �w� � , "4 y iu" � r^ , <br /> IT <br /> r <br /> 01: r�u- �s a .._+ .�.^^.J�.'"z�"r,. ` 'r.8�as: e''"`ti du!. i'i,Rib" i"11 <br />} 11 <br /> TPID- InspectionEll <br /> Inspection Type (Fill one) <br /> Site Suffix: l l ' Q ZRoutine Q Re-inspection Q Referral Q Observation <br /> _Local F) If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> -._._ i . <br /> I <br /> Business or Facility Name r <br /> Inspected By Inspector <br /> L <br /> n <br /> + <br /> Physical Address 1 V 1 I <br /> D —1 + c <br /> Street <br /> Inspection Date <br /> Q <br /> City State Zlp Code Time In Time Out <br /> Business Rep Title [Tj <br /> . _ OM AM <br /> L O AM / i{ Q PM <br /> 1 <br /> - <br /> „,: Operational Status Tire Type Business Role Storage Type <br /> ii (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> O I' Q Closed Q Altered <br /> GPS Latitude m . �I i I--� Q Hauler Q Indoor I <br /> O Q Inactive Q Truck , <br /> Lon Rude Q End-Use Q Container <br /> g Q Planned Q OTR <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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> --- — - - - -- - Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / FT] <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 In Compliance - No Violations <br /> Q Q 'Other: § <br /> Comments ) <br /> '_i .i'.t_( 4i/L(• 1l �t'lY {-�1 t t IJV ^('l+ef �-' k.- �'� i �IV f �. `- <br /> 'J {F >. r,i v^4'l' <br /> tC. o tJ 'JI! "In ..l <br /> Inspection Form Included: Qi <br /> Comments Included: Q - r <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �, w r.,I�?, ,t,�1 P �.] <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X � r� L 1 2 ' ' 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> I <br />