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_ %Waste Tire Su y & Inspection Repor^inspection Report Number State of California - <br /> r CIWMB 181(New 04/04) -' Survey Form - Page 1 i Q r a <br /> California Integrated Waste Management Board -- --O ""-----C <br /> Part A- Surve <br /> BLUE OR BLACK INK PEN <br /> ^� ti�' pi� � ton Details - <br /> TPID- i Inspection Type (Fill one) <br />} Site Suffix: -1 '> Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -, { . - ✓�_ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> Time In Time Out <br /> City State ZIP Code <br /> Business Rep Title 0 AM O AM <br /> 0 PM 0 PM <br /> OPS <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)'.Active 0 Passenger D-Generator 0 Outdoor <br /> �_10 oClosed Altered <br /> Latitude <br /> m— 0 0 Inactive 0 Truck 0 Hauler 0 Indoor <br /> Longitude – ( I Planned OTR End Use Container <br /> 9 <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 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 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 /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / 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/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § --- ----� - <br /> ....- _.._.._.._._._.-- <br /> Comments <br /> y <br /> Inspection Form Included: 0 <br /> Comments Included: 0 -- _ <br /> 'Business Rep's Signature Phone Number Inspector's Signature _ .Phone Number <br /> {, 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X Gfi i o �'d'� I L E 2 3 <br /> ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />