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Waste Tire Su'_ y & Inspection Rep <br /> or ns ection Report Num <br /> ber <br /> State fCalifornia <br /> CIWMB 181(New 04/04) 0 11 <br /> California Integrated Waste Management Board Survey Form Page 1 - 0 $ <br /> w <br /> � <br /> Part A Survey BLUE OR BLACK INK PEN <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: / 4 ('j ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: . --; Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> — <br /> Street r <br /> Inspection Date <br /> City State Zlp Code Time In Time Out <br /> Business Rep _4 Title O AM Q AM <br /> y A O PM Q PM <br /> � r�r{�, <br /> Operational Status t r t rr �r��>i Business RoletMe <br /> Ircu�tni�� moo8elPTE�.,, (Fill one only) (Fill(Fill all that apply) ' Fl�i`ikdjl <br /> ' ® Active �� � � ttf" ® Generatortdcs a <br /> O O Closed <br /> �+ Latitude " °�H" r�au�r 6r+ <br /> GPS J'ary " w1 O Hauler ( ��1d01r" Fi rr <br /> O Inactive T�r {yM it dot y <br /> � <br /> Longitude - O Planned ���` � � ' ��rhtr t End Use <br /> 0 <br /> �','U$11'ley�,5'�y� v Sud t, r r+t v;�' *I 4°�rJ .a ^r r�.k r ✓flr,.a ✓ ,'r, tW.,:L_ yFx rye rt `"d ,thtrY.,,�.1.;k} �" .. ..i',rrc.�"'.r .. . ,. Cr.us.... ._ °,: <br /> ...,: �I, ,..L <br /> Q New Tire Dealer Q Auto Repair Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder O 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 /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Notice Of Violation O Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / FFI / M <br /> 010 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> Inspection Form Included: 0I <br /> Comments Included: 0, _ - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X - 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />