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Report Number <br /> Waste Tire Sulky & Inspection Repor�-inspection_ A p <br /> &aa Sat IWMB California Survey Form - Page 1 1 �/ y V 11 <br /> CIWMB 181(New 04/04) i <br /> California Integrated Waste Management Board _.___. .... ...... .... ..: <br /> Part A- SurveX BLUE OR BLACK INK PEN <br /> gslte I" <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix d J C� 7 � f (6 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: !,� ,, �, �t�.. � O CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ? <br /> V11 _ <br /> L^ <br /> Street <br /> Inspection Date -- �— d <br /> C y ( YState ZIP Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> z� <br /> =_LO PM O PM <br /> a Operational Status � t Business Role . <br /> �axt, ti ✓ � <br /> "I (Fill one only) " (Fill all that apply) <br /> f ® Active ® GeneratorCicr 'x <br /> E—E Eli� —O Closed ;r t f t <br /> GPS Latitude Q Hauler <br /> 0 Inactive <br /> o <br /> LQ End-UseO Planneitude <br /> � <br /> �r) <br /> G err aim r1 iia*�tt: <br /> ��^�� �'''�a"j;., �i,j� 1Y �b�,�" �� .�. x �� 'k d7 t ur r>`i��r hr :'4Y'�.�4 A:.. du �✓1�r ,j <br /> O New Tire Dealer Q Auto Repair Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> O Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> V A Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Part <br /> HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation 0 Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle m <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date I I I m / m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB l I <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT); <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O O 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> l <br /> F � <br /> Comments Included: Q' _. : ... ` <br /> ,Business Rep's Signature Phone Number Inspector s Signature -phorte Numla�r <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X � \/ :r � L� A d u <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® S <br />