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s ection Rp <br /> e ortNumber <br /> Waste Tire Sur & Inspection Report' p __ F <br /> S\ State of California <br /> -a t%F, � G <br /> CIWMB181(New04/04) Survey Form - Page 1 I _ ; , _ €�° 0 <br /> `-`- California Integrated Waste Management Board - - <br /> Pa�hA SurveV BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> ---- -- C- <br /> PID- Inspection Type (Fill one)Site Suffix: / ? EE . 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local —� If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address ` <br /> Street <br /> ------ - Inspection Date -` t <br /> J r <br /> State 7_!P Code. l Time In __--� _ Time Out <br /> Business Rep Title V{ O AM [7- <br /> 0 AM <br /> - -- -- Ope t nal <br /> Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> O <br /> 0 Active Passenger 0 Generator 0 Outdoor <br /> Latitude <br /> 6 i 0 0 Closed 0 Altered <br /> _ I • <br /> GPS � � 0 Hauler 0 Indoor <br /> p <br /> 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> I <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 /> 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 O <br /> 14fCR§18459.3-Retention of Comprehensive Trip Logs for 3 years I <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 /> L..._.-......�._..._,�..�..-_.. ._� .-..,r._.r..-�.. ... ._....... <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - - <br /> _ <br /> ,Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: V M 7w PT, _ 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />