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Waste Tire Sur* & Inspection Report spection Report Number ■ <br /> State of California <br /> 98SG6 <br /> CIWMB 181 survey Form ' Page 1 <br /> - y g <br /> California Integrated Waste Management Board <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> - <br /> Business ProfileZ0ection Details <br /> 00.0 <br /> - ` Inspection Type (Fill one) <br /> Site { <br /> Site Suffix: 9 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: �r - ,? <�•-, - y �(; 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name / <br /> Inspected By Inspector <br /> ,- {-• 1, �: i <br /> Physical Address _ ILl L� I <br /> l�L/ I <br /> &175et <br /> J ` Inspection Date L�I <br /> City State Zil'Code Time In Time Out <br /> T <br /> Business Rep Title O AM AM <br /> 0PM = : QPM <br /> ---.---J I 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 /> Or, <br /> 0 Active 0 Passenger , 0 Generator 0 Outdoor <br /> ® Closed 0 Altered <br /> IGP.S Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility � ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / FTI / 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 t 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments e <br /> ` <br /> Inspection Form Included: 0 <br /> Comments Included: 0' — <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> '� / ++ <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: 62081 <br /> �/ �°, �, i- <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />