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on Ins ectiReport Number <br /> kaL <br /> --Waste Tire Sdy & Inspection Repor ppStatofCalifornia <br /> CIWMB 181(Newg4/04) Survey Form - Page 1 1 4 - 1 0 0 8 0 8 3 <br /> California Integrated Waste Management Board - - <br /> Part A Surve BLUE OR BLACK INK PEN dI <br /> i�P��i'r�°.u���` � n�b M r l iii'"— �FJt W iu:��,�. 'f•v wJe.,1�.,1 <br /> TPID- > I / —� / Inspection Type (Fill one) 1 <br /> Site Suffix: / Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: '; <, r'a. C. n /' <br /> _ � -! Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �— <br /> I ( Inspected By Inspector <br /> Physical Address <br /> r ✓, . / <br /> Street Inspection Date <br /> I_ _.__._. ? Time In Time Out_ <br /> r State ZIP Code _. .___. _ <br /> Business Re Title O AM0 PM AM <br /> � r. a a <br /> i 1 i0 PM <br /> rgl Operational Status Tire Type Business Role Sq <br /> ' �" (Fill one only) (Fill all that apply)', (Fill all that apply) 49� 1 ( <br /> The Count(Whole/PTE) � I, <br /> t <br /> Active Q Passenger Q Generator Q�rikp ; <br /> C Q Closed Q Altered � �,�"F � �a' <br /> GPS Latitude r� Q Hauler 'NW1 <br /> Q Inactive Q T � J <br /> Q <br /> Longitude — � l , I 17TI --.I Q Planned Q OTR Q End-Use Q Container <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 <br /> '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 m / m m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 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 /> QQ 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 Q In Compliance No Violations <br /> Q Q Other: § <br /> Comments <br /> V—�"---L'�t- <br /> Inspection Form included: Q' <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number , <br /> _ 62081 <br /> °' MA �• 9 i -. <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: ; , L - <br /> EWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> f'4 <br />