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Waste Tire S� ey & Inspection Repo ,- _Ins e-c-t-io-n_ Report N <br /> u-mber <br /> State of California <br /> CIWMB 181 <br /> (New 04104) <br /> California IntegraldWaseManagement Board Survey Form - Page 1 1 4 - 10 <br /> 3 V L 4 <br /> � <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Ll <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Li <br /> ' 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local `^ If Referral,choose referral type(Fill one) <br /> Identifier: t ;_,, <br /> (�.=L,{.,�6. t �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name . _ — - -- <br /> ;t <br /> Inspected By Inspector <br /> !Physical Addrr S, <br /> Street - <br /> �, t` j Inspection Date <br /> ct <br /> -- ' ---"--- Time In Time Out <br /> City State ZIP Code ___.__, , <br /> Business Rep Title ', F—T ' � AM � AM <br /> tNG� rr, 1 0VLl rl, / � . PM [T <br /> 0 PM <br /> I _�1 O <br /> VI ;,.� ;I �!( 1rr+t <br /> Operational Status Tire TypeBusiness Role Storage Type <br /> ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tare C011nt '61 I7 <br /> "jA � ® Active Q Passe <br /> n <br /> ger Q Generator Q <br /> Outdoor <br /> Q Closed Q Alred <br /> GPS Latitude EE-1-1 QHauler QIndoor <br /> Q Inactive Q Truck <br /> Longitude F_ T— � <br /> Q Planned Q OTR Q 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 /> i <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 LHAULING 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 -`13esponsible Entities Complying with Manifesting Requirements Date <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 § q g P 9 Y Q -- - - <br /> 14 CCR 18459.3-Retention of Manifest Forms and Tire Tri Logs for 3 ears <br /> Q Q 14 CCR§18460.2-Manifes System Requirements for Registered Waste Tire Haulers Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest Sy em Requirements for Waste Tire End-Use Facilities <br /> Q (1) 14 CCR§18462-Manifest Syste Requirements for Tire Dealers or Waste Tire Generators <br /> p <br /> Q Q Other: § <br /> In Compliance No Violations <br /> I <br /> i <br /> Comments ? (� <br /> f <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 { , f _ _. <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />