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Waste Tire SureyA Inspection Report nspection Report Number <br /> LZSW�c State of California <br /> �� a <br /> CIWMB 181(New 04/04) Survey Form - Page 1 1 1 0 0 0 3 5 <br /> California Integrated Waste Management Board <br /> Part A Surve BLUE OR BLACK INK PEN <br /> i , s n <br /> " r k "r <br /> w <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: (� 7 D Routine Re-inspection <br /> Ld <br /> 0 Referral Observation <br /> ! <br /> - — <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 Inspected By Inspector <br /> I C <br /> Physical Address <br /> 7L <br /> Inspection DateE <br /> E <br /> Street <br /> rj L- <br /> State ZIP Code Time In Time Out <br /> Business Rep TitleAM O AM <br /> ® PM C7 Z I 0 PM <br /> ( <br /> Operational Status d e, r Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Thole/PTE) <br /> ® Active '' �r (D Generator 0 Outdoor <br /> O 0 Closed <br /> C7P5 Latitude �Iri +�r �'k�. 0 Hauler 0 Indoor <br /> D 0 Inactive O Trrt`" <br /> _ 0 End-Use 0 Container <br /> Longitude <br /> Planned OTR <br /> Business Type ae dFill 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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS O 0 <br /> Notice Of Violation 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 carr; srs,., M++ id dry <br /> 0 0 PRC§42956-Registration/Decal in Vehicle ; <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date 0mI <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 I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> a <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance No Violations <br /> 0 0 Other: § <br /> Comments l T ! <br /> I <br /> Inspection Form Included: 01 <br /> Comments .Included: 0, <br /> Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> B a � I: }. _ <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X 62081�, o� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />