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y p p s on Report Number <br /> Waste Tire Sine & Ins Inspection Re or- eInectiorNu <br /> _-- p _- p - _- -- � <br /> xo� � StateBCalifornia Survey Form - Page 1 - "� 0 $ Q <br /> California Integrated W <br /> Part A Surve ate Mana ement Board <br /> BLUE OR BLACK INK PEN <br /> CIWMB 181(New 04/04) <br /> t1�is filet' s Inspection Details <br /> TPID- _ F Inspection Type (Fill one) <br /> Site Suffix: & �(` ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1_,''-i�1 r! y . z- 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 /> City State ZIP Code Time In _ Time Out <br /> Business Rep Title O AM 0 AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type r,? Business Role Storage Type <br /> (Fill one only) (Fill all that apply)1 (Fill all that apply) (Fill all that apply) <br /> ` ® Active ® Passenger (D Generator # Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude �Nt� �� 0 Hauler 0 Indoor <br /> --- . .--. <br /> 0 Inactive 0 True�t��;�r� '• <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that app1Y)j.,r <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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - — -- - <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> r 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 V 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m m <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 t 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 Other: §, <br /> Comments <br /> Inspection Form Included 0, r ;, <br /> 00, 04, <br /> r ,y <br /> ���� In", <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspectar's Signature Phone Number <br /> G� 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X "` �,i,A. ?s 0. T <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />