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Waste Tire Su rr y & Inspection Reportslnspection Report Number <br /> ®®� State of California i n e =-r ■ <br /> CIWMB 181(Now 04/04) <br /> California Integrated Waste Management Board Survey Form " Page 1 i T <br /> i <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: + �j 7 J <br /> 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 /> 1 "f <br /> Physical Address j <br /> Street <br /> Inspection Date <br /> ' I <br /> Cityate 1?Code Time In Time 7 <br /> r,'t,� State Zip Code <br /> Business Rep Title O AM 0 AM <br /> i �,_�� • .__._. 0 PM � _p _. O PM <br /> J _ <br /> Operational Status Tire Type Business Role Storage Type <br /> Fill one (Fill Passenger (Fill all that apply) (Fill all that apply) <br /> The Count(Whole/PTE) ( v) ( apply) <br /> 9 J Q g 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> Latitude <br /> GPS _ 0 Hauler 0 Indoor <br /> T_-- O 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 .I <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 B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 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 /> INSTRUCTIONS ON BACK Correct:® incorrect: �,:� ;A V. � Ll E 62081 <br /> � j L i j <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />