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Inspection Report Number <br /> Waste Tire �ey & Inspection Rep � <br /> 8+ 2 State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 - 1 0 2 5 1 0 7 <br /> California Integrated Waste Management Board <br /> Part A Survey BLUE OR BLACK INK PEN <br /> ME <br /> TPID- Inspection Type (Fill one) <br /> } J <br /> 7 - EE/Site Suffix: i-- Q Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name % Inspected By Inspector <br /> I <br /> Physical Address <br /> Street <br /> Inspection Date <br /> City State Zlf Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> [1] ' [ QPM 0 P <br /> Operational Status Tire Type Business Role Storage Type <br /> e <br /> (Fill one only) (Fill all that apply (Fill all that apply) (Fill all that apply) <br /> n r <br /> , Q Active Q Passenger Q Generator Q Outdoor <br /> G�� Latitude Vo Q Closed Q Altered Q Q <br /> I Hauler Indoor <br /> O Q Inactive Q Truck wo <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> $u,6ltieSa )r at^nply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline= <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q 0 Other: §a <br /> Comments <br /> i✓ a C.' '':':a" ry Yyn a<ngti,a+$.w(; ,(✓'' <br /> :ay r ..rHr% r�.✓r�u,' YaY a r p+t S..(, v >h ( YI,,Yk. :4, Y" Y fa r r ref t ,; 4, :r�.p. i y.rca( 1,g «% . <br /> ,u Sr4r ti" r r t r , <br /> :r qtr" 1 uG6� i''., �"`"' + -!S <br /> In eGtion Form Included ,Y,t"n <br /> p <br /> Comments Included: Q <br /> Business Rep s Signature Phane'Number Inspector's Signature Phone Number <br /> _ ..,rr / <br /> INSTRUCTIONS ON BACK Correct:is firlcorrect: X N/ 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />