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Waste Tire SuMly & Inspection Reporkats <br /> Inspection Report Number <br /> State of California /j� �jJ j/ryt CIWMB181(New 04/04) Survey Form - Page 1 1 , l {_ - 1 01 0 { 6 7 <br /> California Integrated Waste Management Board —_ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> nspection Details <br /> !PID / Inspection Type (Fill one)Site f I Q Routine Q Re-inspection Q Referral <br /> SiteSuffix: Q Observation <br /> Local �'f If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> / Inspected By Inspector <br /> IPhyslcal Address <br /> r /!r I - - <br /> �. <br /> Inspection Date �, < <br /> State ZIP Code Time In Time Out <br /> Business Rep Title O AM mm O AM <br /> W : Fl O PM M : Q PM <br /> Operational Status ire Type Business Role Storage Type <br /> (Fill one only) Fill all that app (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PT <br /> Active Passenger Q Generator Q Outdoor <br /> � Q Closed Altered <br /> GPS Latitude I I I I QHQ <br /> auler Indoor <br /> ,D Q Inactive Q Truck <br /> Longitude – I Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all that apply <br /> „ - <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 /> 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 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 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 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 /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 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 /> Idle � rr r�/:�//��i t , r_'/i < ((.1 e 1 l Lr/ C (a W,; <br /> Inspection r6rrn 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 EXIAMIPILIEI 1112131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />