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spection Report Number <br /> Waste Tire Sur*y & Inspection Report in <br /> 9s714 State of California J <br /> CIWMB 181(New 04/04) Survey Form - Page 1 , 1 1 0 d l 4 8 4 l <br /> California Integrated Waste Management Board --- ------ - --- -- -- I <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> 7!x: <br /> �Inspection Type (Fill one) <br /> r 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local -- If Referral,choose referral type(Fill one) <br /> Identifier: t • \ 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 /> �– — — Time In Time Out <br /> City State ZIP Code __._._— <br /> Business Rep Title 0 AM �� _ AM <br /> BPM - @ PM <br /> I J Lj <br /> y Operational Status M1 , F+°°t1 mess Role ,r� <br /> (Fill one only) til (( til (Fill all that apply) Cetxklltai)', <br /> ,,. fMr <br /> I tI f 0 Active ` � � ' (3 Generator <br /> - � ���� Closed 1 rurg /v E , a ai <br /> Latitude J 1p�"JM ;n� V r, <br /> a) 61n 1i1"r}J� fyf O Hauler <br /> ,— 0 Inactive <br /> 0 End-Use <br /> Longitude 0 Planned SMV' �I ttt 1 <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 ® 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 0 Notice Of Violation 0 Extension <br /> 0 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Datem m <br /> 0 0 / <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required#or NOV or EXT), <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - <br /> i <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 1 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 /> `` - <br /> . - - - --`' ` ._ - _— . - (• �� ,- `) ISI <br /> Inspection Form Included: 0' <br /> t' <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> , , 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X . ; �. ,"", �° i. I- jw <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> I <br />