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Waste Tire Suoy & Inspection Repor Inspection Report Number <br /> Stat e of California � � � 1CIWMB181(New 04/04) Survey Form - Page 1 �1 4 - 01 3 5 <br /> California Integratbd Waste Management Board - --- - - <br /> Part A Survey BLUE OR BLACK INK PEN <br /> ,7:� )n5 efSth�'1'� <br /> 1'r n� ��.��•.,..,,�•,.�.t�5t �,�,w`.,-�.� ,r3,'�„ '�..�..�^v�.�'stir dE <br /> ar�,e,' .+r.�. .,�. .1;,�"e.s..� <br /> TPID- ) _ �j 7 ` Inspection Type (Fill one) <br /> 1Site Suffix: f ; Q Q Routine Q Re-inspection Q Referral x? Observation <br /> Local -- ( If Referral,choose referral type(Fill one) <br /> Identifier: L Ij 0 <br /> y'i /'1 C i c ;. (/l L 0, ,t:i1-j 4, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name j <br /> -: Inspected By Inspector <br /> r - ( j.. �, -fit i l_� c_� J _ <br /> Physical Address <br /> Street /l <br /> Q ;: � Inspection Date <br /> City ( ( �' State ZIP Cone. i Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> QPM (_ QPM <br /> Operational Status Tire TypeW <br /> Business Role Storage Type <br /> (Fill one only) (Fill all tha (Fill all that apply) (Fill all that apply)' <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> �i oClosed Q Altered <br /> GPS , Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> IWe' <br /> Longitude — F I <br /> JQ Q Planned Q OTR Q End-Use Q Container <br /> fin„ <br /> Business Type '(Fill all 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 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 Q Notice Of Violation Q Extension <br /> Q O 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 /> QO 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 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 /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other' <br /> Comments <br /> L-- rt G' ( QT��5`/ v.. I - IT{ .�.� V� /�• • __�ll r.f /� �.% ��1 � �r y j�l:t fl.. _.. I:.t{ f !... T <br /> 1 j h-%��'f;^ t odi fir&j <br /> Inspection Farm Included: Q <br /> Comments Included: Q, <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ o .__. <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: 62081 <br /> V e i; '��o �. I t <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />