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Waste Tire Suy & Inspection Reportanspection Report Number <br /> Wiai� i State of California <br /> IM CIWMB 181(New 04/04) SUrve Form - Page 1 I s o <br /> y <br /> California Integrated Waste Management Board <br /> Part A- Survuv BLUE OR BLACK INK PEN_ <br /> °Business Profile itspectidn.Details <br /> TPID- ! Inspection Type (Fill one) <br /> Site Suffix: Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local <br /> Identifier: If Referral,choose referral type(Fill one) <br /> _ T <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> — — _ <br /> Business or Facility Name Inspected B <br /> p Y Inspector <br /> --. __L,�__� _ __ _ __ -- —i <br /> Physical Address <br /> I Streets <br /> Inspection Date / L—H / Ld� <br /> City Sta#e 76P Codi I Time In Time Out <br /> Business Rep TitleII Q AM — �� AM <br /> __._.__ .. PM ._.. . _ O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> l0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> . .� ._.;l .,. <br /> io Q Inactive 0 Truck <br /> Longitude 0 End-Use 0 Container <br /> _ _ 0 Planned 0 OTR <br /> - _ - - <br /> Businesls Type (Fill all that a ! <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 Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A <br /> HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 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 <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 <br /> Inspection Form Included: 0 <br /> Comments Included: 0' . <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X L XGA I ,�P <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />