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Waste Tire Survey, Inspection Report In, <br /> State of California p N ection Report Number <br /> 1. <br /> 7 CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> A- Survey 0 6 o � <br /> ness Profile Inspection Details BLUE OR BLACK INK PEN <br /> Suffix: j [j _ Inspection Type (Fill one) <br /> ,l * Routine Q Re-inspection Q Referral <br /> ccpp Q Observation <br /> :ifier: 5 t�\�bC�ep o', �� If Referral,choose referral type(Fill one) <br /> less or Facility Name Q CIWMB Q Complaint Q Educational Visit Q Other <br /> �S ;� I , U_5 I Inspected By <br /> cal Address <br /> u�/�/l, � _ Inspector <br /> � <br /> 5 � l o <br /> Al , / Inspection Date ( V / <br /> -5, / <br /> 'ss Rep Time In <br /> Title Time Out <br /> L _ O AM Q AM <br /> 0 PM O PM <br /> Count(Whole/PTE) Operational Status Tire Type Business Role Storage T <br /> (Fill one only) (Fill all that apply) Type <br /> pp y) (Fill all that apply) (Fill all <br /> that apply) <br /> ® Active 0 Passenger Generator <br /> Latitude 0 Q Outdoor <br /> Q Closed Q Altered <br /> Longitude 0 ® Truck <br /> Q Inactive Q Hauler ® Indoor <br /> _ <br /> ss Type (Fill all that apply) Q Planned Q OTR Q End-Use Q Container <br /> Tire Dealer Q Auto Repair <br /> Trucking Fleet Q Government <br /> Q Retreader Q Dismantler <br /> I Tire Dealer Q Auto Body Q Car Dealer Q Tire Derived Fuel <br /> Q Collection Q Crumb Rubber <br /> ice Station Q Hauler <br /> Q Agriculture Q Shredder <br /> Q Other <br /> - Inspection of Waste Tire Dealer Generator Hauler and End-Use Facility <br /> HAULING AND MANIFEST REQUIREMENTS ENFORCEMENT STATUS <br /> — - - . --. <br /> RC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. O Notice Of Violation Q Extension <br /> PRC§42956-Registration/Decal in Vehicle Compliance Deadline <br /> 14 CCR§ 18459 -Responsible Entities Complying with ManifestingRequirements <br /> a (b c q ments <br /> 14 CCR§ 18459.1 ) i )-Tire Program ID Date Number from CIWMB <br /> 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip L m <br /> 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs forv3 years days (RequiredforNOVorEXT) <br /> 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities Q Referred/CIWMB Enforcement <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: § <br /> -- <br /> _- -— - In <br /> --- Compliance <br /> No Violations i <br /> its <br /> i 1 LLt 5- 5wu- <br /> •4 `� l-1 <br /> -orm Included: <br /> cents Included: Q •�/L� 3 r t <br /> P <br /> Business Rep's Signature � <br /> Phone Number <br /> berr Inspe or's Signat e l b <br /> _ Phone Number <br /> TRUCTIONS ON BACK Correct:* Incorrect: Ilk I <br /> XIW ���t P (_� ( , 62081 <br /> _ <br /> White Copy:CMB Yellow Copy cr ope,, Pink Copy:LEA L <br />