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® spection Report "umber <br /> Waste Tire Sur*y & Inspection Report n <br /> EE C='. State of California <br /> �� ® Survey Form - Page 1 8 1 0 2 5 8 5 3 <br /> CIWMB 181(New 04104) - <br /> California Integrated Waste Management Board LUE OR BLACK IN PEN <br /> Part A- Survey B ,: <br /> Buslness_,:Prof Ie �a <br /> Inspection Type (Fill one) <br /> Ste Suffix: Routine Q Re-inspection Q Referral Q Observation <br /> Local -^ If Referral,choose referral type(Fill one) <br /> Identifier: __ `w., Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> c <br /> Physical Address <br /> Street Inspection Date `7 <br /> -- State ZIP Code Time In Time Out <br /> City F—LI : <br /> Busmess Rep Title ��O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> "Fire Count(Whole/PTE .��,, <br /> hQ Active Q Passenger Q Generator Q Outdoor <br /> �S Latitude <br /> G LtitdW , ��o ® Closed Q Altered Q Hauler Q indoor , <br /> ���O I Q Inactive Q l ruck <br /> Longitude – F771, , � T1_1 Q PlannedQ OTR Q End-Use Q Contalnel <br /> :itts@@ ass 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 /> - – - 7 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 'HAULING AND MANIFEST REQUIREMENTS _ 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 / m <br /> Q Q s and Tire Trip Logs within 90 days <br /> 14 CCR§ 18459.1 (a)(b)(c)-The Program ID Number from CIWMB <br /> Q Q (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Manifest Form <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 /> 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 /> ?� <br /> Inspection Form Included: Q <br /> Comments Included: Q - _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number._ ; <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X ' _ L i I i <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> ® <br />