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Waste Tire Su* & Ins ection Re or. inspection Report Number <br /> Y p p <br /> iIII. CIWM 181(New Survey Form - Page 1 19 - 1 0 0 0 0 7 2 <br /> CIWMB 181(New 04/04) <br /> Califomia Integrated Waste Management Board <br /> Part A- Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r( Inspection Type (Fill one) <br /> Site Suffix: -5� - b U ` Q Routine Q Re-inspection Q Referral Q Observation <br /> Local <br /> If Referral,choose referral type(Fill one) <br /> Identifier: 50.11 �� `t l� �bl Q CHP O CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address J 1 tJ ` ��OL y C'7-Z roz�t <br /> Inspection Date \ p ` © S <br /> Time In Time Out <br /> Business Rep Title O AMAM <br /> ��� � u \ V � BPM - �-� � -®'P MM <br /> l Fill one only) (Fill all that apply) Business Role Storage Type <br /> Operational Status Tire Type <br /> Tire Count (Whole/PTE) /� D ( y> PP Y) (Fill all that apply) (Fill all that apply) <br /> `� ® Active Q Passenger ® Generator ® Outdoor <br /> O <br /> Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> O Q Inactive I� (k)Truck <br /> Longitude - O Planned Q OTR RJ End-Use (ilk 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 O Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> O Service Station O Hauler O Agriculture Q Shredder Q Other <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FENFORCEM—EN T STATUS <br /> V-1 A 1 HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / m <br /> Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days „(Required far NOV or DC7) <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years " t , <br /> c r <br /> o O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers :Q Referred/CIWMB Enforcement <br /> O O 14 CCR 18461 -Manifest System Requirements for Waste Tire End-Use Facilities i ria. <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 (� In Compliance No Violations <br /> Othor: § <br /> CommentsQhml 45 <br /> ACLI � t <br /> Inspection Form Included: Q <br /> Comments Included: Q - - -- -- ---- - - -- - __ _h -- <br /> ess Re Signature Phone Number Ins ector's Signa ure Phone Number <br /> INSTRUCTIONS ON BACK j Correct:' <br /> orrect - Incorrect -Xp� , E X R, P 1 Z 3 62081 <br /> White Copy:CIWMB .� Yellow Copy:Operator Pink Copy:LEA <br />