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Waste Tire Sur0y & Inspection Report nspecton Report Number <br /> State California <br /> CIWMB <br /> 181(New 04/04) -Survey Form Page 1 - 10 1 0 5 0 3 <br /> - � <br /> California Integrated Waste Management Board _- <br /> Part A- Survev BLUE OR BLACK INK PEN <br /> ���.•'` a I��ta�Ss r r" � s +r' rri :k � � � - -- <br /> TPID- 1 _ Inspection Type (Fill one) <br /> Site Suffix: ' ✓ ` ! ''i �-` / Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: CHP CIWMB Complaint Educational Visit Other <br /> art, �� /�s. � O O O p O O <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> .. _. <br /> Street <br /> _ Inspection Date <br /> City 1 State ZIP Code Time In ETime Out <br /> Business Rep Title � AM � AM <br /> M : � PM O PM <br /> Operational Status Tire k? d, Business Role Storage Type <br /> " •' (Fill one only) (Fillal(,;,t,' �, (Fill all that apply) (Fillallapply) <br /> Tire Cunt {Whole/PTE) <br /> Q Active Q Generator Q Outdoor <br /> 0 <br /> ® �la� <br /> GPS Latitude Closed Q a4l <br /> m � <br /> `cc k <br /> Q Hauler Q Indoor <br /> Inactive Tru <br /> C Q <br /> Longitude <br /> Q Planned Q OTR I O End-Use Q Container <br /> Business 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 h <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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O 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 /> O O <br /> 14 CCR 18459.1 a b c -Tire Program ID Number from CIWMB M / M m <br /> 14 CCR 18459.2.1 -Submittal of Manifest Forms and Tire Tri Logs within 90 days <br /> (Required for NOV or EXT) <br /> O O § P 9 Y <br /> Q O 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 t CIWMB Enforcement <br /> Q O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O i O 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 /> t��;(,{ �(_✓'�.i i �� c, ( 1 (tai}\ f ✓'t-t _ !=� a ! � E t ��' li_���(;,;-+ <br /> t_'1( F <br /> V ✓ d^.Inlr' `_> ` �i►l� ��ir k/eFt � r� f �/�GeCl rtY -<;C � q t/yr.tt3✓S <br /> 1j J J <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 A, <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />