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■ uW �, Waste Tire Su&y & Inspection Report Inspection Report Number <br /> @Cw32Zc State of California <br /> CIWMB 181(New 04/04) <br /> `rte° <br /> California Integrated Waste Management Board SurveyForm - Page 1 1 8 - 10 1 330 <br /> Part A Survey BLUE OR BLACK INK PEN <br /> i TPID- Inspection Type (Fill one) <br /> Site Suffix: ' r C� C� �j S ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �� _ If Referral,choose referral type(Fill one) <br /> Identifier: - + " r Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> - - -- - <br />' Business or Facility Name ' <br /> Inspected By Inspector fl <br /> Physical Address C ! VQ <br /> Street <br /> Inspection Date -, rQ <br /> City State ZIP Code Time In Time Out <br /> Business Re <br /> p Title 0 PM � 0 PM <br /> i <br /> —�_j I Operational Status Is Business Role Storage Type <br /> (Fill one only) (fG )� � }tiO! (Fill all that apply) (Fill all that apply)LLJLL <br /> ', <br /> Q Active �}F� ftIY, Q Generator Q Outdoor <br /> Latitude <br /> D Q Closed Q RI� t" �)" �s �, <br /> GPS Hauler 0 indoor <br /> Q Inactive <br /> Longitude - , QQQ� Q Planned Ql OTR Q End-Use Q Container <br /> Business Type (Fill ail 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 /> / r <br /> Q Service Station Q Hauler Q Agriculture Q Shredder (j) Other f <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A i; <br /> 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 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 /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance- No Violations <br /> O Q Other: § <br /> Comments 'Q <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 X i <br /> ■ White Copy:CIWMB Yellow Copy:Operator � Pink Copy:LEA � � ■ <br />