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Waste Tire SLAy & InsReports!" <br /> or Inspection Report Number <br /> Inspection Re p <br /> State of California ' <br /> &dub <br /> CIWMB 181(New 04/04) e 1 <br /> California Integrated Waste Management Board Survey Form Page - --I1- - - - -- - <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> SUiI blr .* nspectan Details <br /> TPID- ii __ Inspection Type (Fill one) <br /> Site Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local - S If Referral,choose referral type(Fill one) <br /> Identifier: !,+ { j, d, ! Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> - <br /> Business or Facility Name { Inspected By Inspector <br /> i�� <br /> Physical[ Address <br /> Street <br /> ection Date' Ins <br /> 1 <br /> j <br /> City '' State ZIP Code Time In Time Out <br /> Business Rep Title _,._.. 0 AM [:E � AM <br /> O PM O PM <br /> Al <br /> Operational Status Tire Type Business Role storage Type <br /> 17' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> Active Q Passenger (3,Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor 1=10 <br /> D Q Inactive Q Truck <br /> fi r- -7 <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (rill alt 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder (a Other r�n <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 - Responsible Entities Complying with Manifesting Requirements Date FFI / 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 O - _ <br /> 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 <br /> Q In Compliance - No Violations <br /> Q Q Other: § -- ---- <br /> Comments r <br /> L <br /> I o _ <br /> +,3r=fib `n ,i:�o� '✓ w"` W'v� � J;R,n 's ��r1 ��, S4 1. alit r�rr �M J:�:. ''�'� i hu Y + �>&z n,�G,y �+✓Wy"�r� �k,: <br /> n � <br /> INSTRUCTIONS ON BACK <br /> : Correct:* Incorrect: ,�' �/� _ `; , � , 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />