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Waste Tire SurWl & Inspection Report nspAeyction Rf'eportl�Nu/mber ■ <br /> ffiC;ar StateBCalifornia Survey Form - Page 1 1 L 1 Y 13 4 6 4 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board ----- - --- - --- -- <br /> Part A- Survey <br /> { BLUE OR BLACK INK PEN <br /> S tk+t�1!I'ly", "�I" " •r "".t� ,.... ,„ . 'r r �i ap}at " ah " � ,M01 <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: L� _ I M� 0 Routine Q Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: i r. 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> CitL State ZIP Code Time In Time Out <br /> Business Rep Title O AM � /t� �- ($AM <br /> PM –�_. O PM <br /> Operational Status a r Business Role <br /> -A <br /> (Fill one only) 9��i ads (Fill all that apply) <br /> r ® Generator (�� <br /> ® Active <br /> D 0 Closed, <br /> Latitude f ,t <br /> 0 Hauler <br /> GPS ��a � <br /> 0 Inactive <br /> Longitude – 0 Planned0 End-Usei r ra {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 ( Other ; iii•. r i i ,:: <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> i <br /> 0 0 �PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required'for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 In Compliance - No Violations <br /> 0 0 Other: § _-- —__-- <br /> Comments <br /> f <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �, �/ -_uz. d' 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />